Podcasts about CSF

Dr. Jay Fisher is back on PEM Rules to discuss his experience with Bacterial Meningitis, a rare (and terrible) condition that is high on my list of "I Never Want to Miss It". Here are the articles Jay discussed: References Clinical Features Suggestive of Meningitis in Children:A Systematic Review of Prospective Data. Pediatrics 2010;126(5);952-960. https://pubmed.ncbi.nlm.nih.gov/20974781/ Bulging fontanelle in febrile infants as a predictorof bacterial meningitis. European Journal of Pediatrics (2021) 180:1243–1248. https://pubmed.ncbi.nlm.nih.gov/33169238/ Here is the link to the picture of the CSF of the patient discussed in the episode.  https://pemrules.com/wp-content/uploads/2024/12/csf.png  

From striped bass policy to black bear hunting, Fred Bird breaks down this week's biggest wins for America's sportsmen. New Hampshire Governor Kelly Ayotte officially joins the Governor's Sportsmen's Caucus, continuing the state's long tradition of leadership in defending hunting and angling heritage. Fred also spotlights CSF's new Rocky Mountain States Coordinator, Nate Serlin, and his role working with the Legislative Sportsmen's Caucuses in Colorado, Idaho, Montana, New Mexico, and Wyoming. On the fisheries front, the Atlantic States Marine Fisheries Commission decides to maintain striped bass regulations, averting unnecessary closures for thousands of saltwater anglers. Down south, Florida's outdoor community celebrates major conservation wins, from saving the Rodman Reservoir bass fishery to reinstating a science-based black bear hunt. Fred also covers how the U.S. Senate voted to uphold science-based wildlife management, defeating an anti-hunting proposal targeting owl conservation, and explains why access without habitat is meaningless for hunters and trappers nationwide. If you care about how policy affects the woods, waters, and wildlife you love, this is your weekly must-listen briefing from the front lines of conservation.   Get the FREE Sportsmen's Voice e-publication in your inbox every Monday: www.congressionalsportsmen.org/newsletter   Follow The Sportsmen's Voice wherever you get your podcasts: https://podfollow.com/1705085498  Learn more about your ad choices. Visit megaphone.fm/adchoices

Welcome to the NeurologyLive® Mind Moments® podcast. Tune in to hear leaders in neurology sound off on topics that impact your clinical practice. Following the 2025 Alzheimer's Association International Conference (AAIC), Rebecca Edelmayer, PhD, outlines the Alzheimer's Association's first clinical practice guidelines for using blood-based biomarkers (BBMs) in the diagnostic workup of suspected Alzheimer's disease within specialized care. She explains the guideline mission, how tests were evaluated for accuracy, and when BBMs should serve as triage versus confirmatory tools relative to CSF and PET. Edelmayer details current scope limits (cognitively impaired patients in specialty settings), cautions against overextending to primary care or unimpaired populations, and previews the education roll-out—executive summaries, micro-learning modules, and shared decision-making resources. She closes with research priorities: stronger peer-reviewed reporting, broader validation across diverse populations and settings, and building an equitable pathway that leverages BBMs to speed accurate diagnosis and treatment access. Looking for more Alzheimer & dementia discussion? Check out the NeurologyLive® Alzheimer & dementia clinical focus page. Episode Breakdown: 1:05 – Understanding the purpose and mission behind new blood-based biomarker guidelines 2:05 – Key recommendations and defining triage vs confirmatory blood-based biomarker use 3:15 – Clinical precautions and where blood-based biomarkers are appropriate today 5:30 – Neurology News Minute 7:45 – Educating clinicians on implementing BBMs in specialty care 10:15 – Research priorities to strengthen evidence and ensure equity The stories featured in this week's Neurology News Minute, which will give you quick updates on the following developments in neurology, are further detailed here: FDA Accepts New Drug Application for Tau PET Imaging Agent MK-6240 in Alzheimer Disease B-Cell Modulator Obexelimab Shows Pronounced Relapse Reduction in Phase 2 MoonStone Trial Subcutaneous Efgartigimod Shows Efficacy in Phase 2 ALKIVIA, Phase 3 ADAPT SERON Trials Thanks for listening to the NeurologyLive® Mind Moments® podcast. To support the show, be sure to rate, review, and subscribe wherever you listen to podcasts. For more neurology news and expert-driven content, visit neurologylive.com.

First, The Indian Express' Deeptiman Tiwary talks about Prashant Kishor's Jan Suraaj party and how the political-analyst-turned-politician is trying to distinguish himself from others ahead of the upcoming Bihar polls.Next, The Indian Express' Anjali Marar explains the cloud-seeding method that the Delhi government hopes will help reduce pollution, and why experts believe it's a flawed technique (18:54).And finally, we bring you an update on the case involving two Australian cricketers who were sexually harassed in Indore last week (29:44).Hosted by Shashank BhargavaProduced by Shashank Bhargava and Ichha SharmaEdited and mixed by Suresh PawarAdditional Links:1) CSF |  Green Shoots of Progress for Uttar Pradesh2) CSF | Academic and Governance Inputs for NIPUN Bharat Mission3) CSF |  The need for better Public Disclosure in schools4) CSF | The evolving space for AI in Education

Crowd-Sourced Funding (CSF) Equity Raising: a real, underused pathway for SMEs – and a powerful advisory opportunity for your firm. In this episode of Accountants Minute Podcast, Peter Towers busts the myth that only unlisted public companies can raise via CSF, explains the ASIC-licensed intermediary model, and shows how accountants, bookkeepers and advisors can prepare SME clients to raise up to $5M without a prospectus. You'll learn where firms add the most value – investment-readiness (plans, budgets, cashflow forecasts, governance), crafting the CSF Offer Document, and converting post-raise support into ongoing Virtual CFO work. You can also access our podcast on: Amazon Music Apple Podcasts Audible Spotify YouTube

This episode of the Blue Dragon podcast features Jason Brown, a seasoned cybersecurity leader, former CISO/vCISO, and author, discussing his book, "Unveiling NIST Cybersecurity Framework 2.0". The conversation centers on the NIST CSF 2.0, emphasizing the critical addition of the "Govern" function. Jason frames the CSF as an excellent introductory framework for building a cybersecurity program, often used in conjunction with the Center for Internet Security (CIS) controls. A key theme is moving cybersecurity beyond a technical "IT problem" and a "checkbox exercise" to a strategic business value driver that builds trust and unlocks revenue. Both speakers highlight the growing global focus on supply chain security (NIST CSF, NIS2, DORA) and the rising personal liability and accountability for CISOs and executives in the US and Europe. The discussion concludes with a deep dive into the importance of a well-structured three-layered documentation approach (Policy, Standard, and Procedure) and a formalized document lifecycle to maintain organizational security maturity.LINKS➰ https://bluedragonpodcast.com➰ linkedin.com/in/jasonbrown17➰ jason@jasonbrown.us➰ https://jasonbrown.us➰ Book: bit.ly/Unveiling-NISTCHAPTERS(00:00:00) 00:00:00 Introduction (Guest: Jason Brown, Author) (00:03:39) Guest Background & Path to Writing NIST CSF 2.0 Book (00:05:20) Core of NIST CSF 2.0: The addition of the 'Govern' function (00:06:34) Primary Driver for CSF 2.0: Supply Chain Governance (00:08:05) CSF's Role: An introductory framework, often paired with CIS Controls (00:09:21) Security as a Value Driver: Moving past compliance for revenue and trust (00:11:48) CISO's Role: Building relationships for program and financial support (00:14:00) Common Mistakes: Failing to assess gaps or focus on the 'how' (00:15:48) Overview of the Six CSF Functions (Govern, Identify, Protect, Detect, Respond, Recover) (00:17:43) Prioritizing Governance: It is the hardest step due to changing people (00:19:32) Overcoming Governance Hurdles: Dialogue with Executive Leadership Teams (ELT) (00:21:20) Executive Accountability: Personal liability and fines (US SEC, EU NIS2) (00:25:54) Communicating Value: Use Enterprise Risk instead of technical jargon (00:27:53) Security as a Business Problem: Not just an IT problem (Jaguar example) (00:30:41) Engaging Leaders: Involving department heads in identifying critical assets (ID.BE) (00:32:19) Future CSF Evolution: Expected integration of AI and emerging technologies (00:33:36) Three-Layered Documentation: Policy (what), Standard (guidelines), Procedure (how-to) (00:37:05) The Open Policy Framework: Jason's structured documentation approach (00:38:02) Document Lifecycle: Annual review prevents reliance on outdated, breakable standards (00:40:04) Personal Updates: Break from writing for family time (00:40:29) Automotive Industry Security: Brief mention of OT concernsKEYPOINTS1. NIST CSF 2.0's "Govern" function is key for a complete cyber program; it is the most critical starting point due to the challenge of changing people.2. Cybersecurity must be framed as a business value driver and revenue generator, moving past a simple compliance checklist mentality.3. The CISO's role is strategic: acting as a business enabler by communicating security needs via enterprise risk to the ELT.4. Global regulations (NIS2, SEC) are increasing personal liability for executives, making robust governance mandatory, not optional.5. A strong governance structure uses three distinct layers: Policy (public commitment), Standard (confidential guidelines), and Procedure (technical configuration).6. Security documents must have a formal lifecycle with annual reviews to ensure standards remain current and effective against threats.

Tumor components and immune response indicators can be found in cerebrospinal fluid, or CSF, when someone has a brain tumor, in a new test developed by Chetan Bettagowda, director of neurosurgery at Johns Hopkins and one of the test's developers.  … Cerebrospinal fluid may hold the keys to brain cancer identification and treatment, Elizabeth Tracey reports Read More »

Testing a fluid known as cerebrospinal fluid, or CSF, found surrounding the brain and spinal cord, reveals a lot about brain tumors and the immune response to them. Johns Hopkins neurosurgery department director Chetan Bettegowda and test developer says this … Can a new test of cerebrospinal fluid be used for many diseases of the brain and spinal cord? Elizabeth Tracey reports Read More »

Your brain and spinal cord are floating in something called cerebrospinal fluid, or CSF, and when brain tumors develop they shed cells and cellular components into this fluid. A new test developed by director of neurosurgery Chetan Bettegowda at Johns … Cerebrospinal fluid can tell lots about brain tumors, Elizabeth Tracey reports Read More »

In today's episode, Dr. Monica Gray and Dr. Pradip Kamat sit down with neurosurgeon Dr. Neal Laxpati, MD, PhD, to chat about intracranial pressure (ICP) monitoring in pediatric critical care. Using real case studies, they dive into how and when to use external ventricular drains (EVDs) and ICP bolts, walking listeners through setup, potential risks, and everyday challenges. The group discusses device complications, ways to prevent infections, how to interpret waveforms, and shares practical bedside tips. It's a must-listen for intensivists looking for hands-on advice and key insights to help optimize care for kids with brain injuries or hydrocephalus.Show Highlights:Pediatric critical care unit (PCU) case discussionsIntracranial pressure (ICP) monitoring in pediatric patientsCase studies involving a 10-year-old girl with diffuse midline glioma and a 16-year-old male with a ruptured arteriovenous malformation (AVM)Cerebrospinal fluid (CSF) physiology and its role in ICP managementTypes of ICP monitoring devices: external ventricular drains (EVDs) and intraparenchymal monitorsIndications and complications associated with ICP monitoringInterpretation of ICP waveforms and their clinical significanceManagement strategies for elevated ICP and CSF drainageRisks and challenges of ICP monitoring, including infection and device malfunctionImportance of interdisciplinary communication and meticulous bedside care in pediatric critical care settingsReferences:Fuhrman & Zimmerman - Textbook of Pediatric Critical Care Chapter 118. Traumatic brain injury. Kochaneck et al. Page 1375 -1400Rogers textbook:Reference 1: Forsyth RJ, Parslow RC, Tasker RC, Hawley CA, Morris KP; UK Paediatric Traumatic Brain Injury Study Group; Paediatric Intensive Care Society Study Group (PICSSG). Prediction of raised intracranial pressure complicating severe traumatic brain injury in children: implications for trial design. Pediatr Crit Care Med. 2008 Jan;9(1):8-14. doi: 10.1097/01.PCC.0000298759.78616.3A. PMID: 18477907.Reference 2: Appavu B, Burrows BT, Foldes S, Adelson PD. Approaches to Multimodality Monitoring in Pediatric Traumatic Brain Injury. Front Neurol. 2019 Nov 26;10:1261. doi: 10.3389/fneur.2019.01261. PMID: 32038449; PMCID: PMC6988791.

As part of our ongoing collaboration with Central Square Foundation, we are excited to bring to you the fourth episode of our five part series where we talk about the evolving landscape of AI in Education.The National Education Policy 2020 marks a bold shift in how we think about technology in learning. It envisions a future where students build not just digital literacy, but also computational thinking and AI fluency — and where teachers are empowered with the tools, training, and support to integrate AI into their curriculums meaningfully and responsibly. To understand how this is being implemented, we'll be joined by Gouri Gupta, Sr. Project Director of EdTech who leads CSF's work in EdTech and AI and Professor Balaraman Ravindran, Head, Wadhwani School of Data Science & AI (WSAI), IIT Madras who is one of India's top AI researchers and has helped shape India's AI policy framework and currently advises the Reserve Bank of India on the uses of AI in finance. Hosted and produced by Niharika NandaEdited and mixed by Suresh PawarLinks to the previous episodes of our series with CSF:Episode 1Episode 2Episode 3

Send us a textA newborn with higher pTau217 than an adult with Alzheimer's—what would that mean for how we detect, define, and treat dementia? We dive into a startling new finding that reframes tau phosphorylation as a dynamic, reversible process rather than a one-way street. From the costs and tradeoffs of PET scans and CSF analysis to the promise of new blood tests, we lay out how clinicians navigate biomarkers and why context matters. If babies and even hibernating animals can toggle tau safely, we might be looking at a new horizon for Alzheimer's research—one that prioritizes regulation over blunt suppression and respects the difference between signals and symptoms.Then we turn to our dogs and a different kind of brain science: play that looks a lot like behavioral addiction. In a study of high-drive pets, some dogs pursued play so intensely they ignored food and struggled to settle once the toy disappeared. The kicker? It's not the toy—it's the play. We unpack how anticipation and reward loops shape behavior, why shepherds and terriers tend to lean in hard, and how to channel that energy with structured games, clear start/stop cues, and decompression routines that protect both joy and well-being.Our guest, Dr. Nancy Kay—veterinarian and small animal internal medicine specialist—brings practical wisdom to family life with pets. She explains how to choose a dog that truly fits a home with kids, why supervision and respect rules beat wishful thinking, and how to steer clear of puppy mills and dog auctions with two simple safeguards: never buy from pet stores and never purchase sight unseen. We talk about her middle-grade novel, “A Dog Named 647,” her advocacy guide “Speaking for Spot,” and the unforgettable cases that come with a life in medicine—from swallowed treasures to high-stakes rescues. It's science that matters, compassion that lasts, and stories that stick.Enjoy the conversation? Follow, share with a friend, and leave a quick review to help more curious listeners find the show.Dr. Nancy's Links:A Dog Named 647Her WebsiteOur links!Support the showFor Science, Empathy, and Cuteness!Being Kind is a Superpower.https://twitter.com/bunsenbernerbmd

Episode 204: Adult Pneumococcal Vaccines in 2025.  Luz Perez (MSIV) presents all the available pneumococcal vaccines for adults. Dr. Arreaza guides the discussion about what to do with adults who have previously received pneumococcal vaccines. Written by Luz Perez, MSIV, Ross University School of Medicine. Comments by Hector Arreaza, MD.You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.Today we're answering a clinic classic: Which pneumococcal vaccine should my adult patient get—and when? This is an update of episode 90.Why pneumococcal vaccines matter?Pneumococcal vaccines prevent infections caused by the bacteria Streptococcus pneumonia. These bacteria can cause serious infections like pneumonia, meningitis, and bacteremia. In 2017, the CDC reports that there were more than 31,000 cases of pneumococcal infections and 3,500 deaths from invasive pneumococcal disease. Children are vaccinated in early childhood, before age 5, with PCV15 or PCV 20, at the age of 2, 4, 6 months and a last dose around 12-15 months. Why do we vaccinate adults?Adults are vaccinated because they're at higher risk of getting pneumococcal disease or of having worse outcomes if they do. Vaccines are important because they protect these at-risk patients and reduce the spread of infections among communities. What are the available vaccines? PCV vs PPSV.There are two pneumococcal vaccines used in practice: a polysaccharide vaccine (PPSV) and a conjugate vaccine (PCV). Both protect by targeting capsular polysaccharides from pneumococcal serotypes most often responsible for invasive disease. In simple terms, these vaccines target a part of the bacteria “coating” and create antibodies or proteins that protect the body when the strep enters the body. PPSV (polysaccharide): PPSV is made from purified pieces of the pneumococcal capsule or coating. The current vaccine PPSV23 (Pneumovax®) covers 23 serotypes (or strains) that were the leading cause of pneumococcal infections in the 1980s. PCV (conjugate): Pneumococcal conjugate vaccines (PCVs) take capsular polysaccharides from the bacterium and chemically link them to a carrier protein, which changes and strengthens the immune response. Current PCVs come in four versions: PCV13 (Prevnar 13)PCV15 (Vaxneuvance)PCV20 (Prevnar 20)PCV21 (Capvaxive) The number indicates the amount of pneumococcal capsule types covered by each vaccine. PCV21 was designed around adult disease patterns and covers many serotypes currently driving invasive disease in adults. However, it does not include serotype 4, but this serotype is covered by the PCV20 and PCV15.Who should be vaccinated? In 2024, the United States Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) updated their recommendations on Pneumococcal vaccinations for adults. Their recommendations are: Everyone 50 years or olderAdults age 19–49 with risks: chronic lung/liver disease, heart failure, diabetes; CSF leak or cochlear implant; immunocompromised states (e.g., HIV, hematologic malignancy, CKD/nephrotic syndrome); functional/anatomic asplenia.Patients with history of prior invasive pneumococcal disease: still vaccinate. What vaccine should be given for adults that have never received the Pneumococcal vaccine?For eligible adults with no prior pneumococcal vaccines, there are three choices:PCV21 oncePCV20 oncePCV15 now, followed by PPSV23 later, usually 1 year; 8 weeks if immunocompromised, CSF leak, or cochlear implant.PCV 20 or PCV21 seem more convenient. Once and done. If available, PCV21 is a great one-and-done pick for most adults because it's tailored to current adult serotypes.Serotype 4 caveat: If your patient is at higher risk for serotype 4 disease—think Navajo Nation, or folks in the Western US/Canada with substance use disorders or experiencing homelessness—choose PCV20 (or PCV15 followed by PPSV23 if PCV20 isn't available).What if the patient already received a Pneumococcal vaccine in the past?Plan depends on which vaccine they received and when.PPSV23 only: give PCV21 ≥1 year later (or PCV20 if serotype-4 risk or PCV21 unavailable).PCV10 or PCV13 only: give PCV21 (or PCV20 if PCV21 unavailable) ≥1 year later. If a PCV is not available, discuss PPSV23 now vs waiting until PCV is available.If patient receives PPSV23 now will need to return ≥1 year later to receive a PCV vaccine, and no more vaccines are needed after that.Is it safe to administer the Pneumococcal vaccine with other vaccines?Coadministration is fine with other non-pneumococcal vaccines, as long as we use different syringes and sites. Data support same-day administration of PPSV23 + influenza, and PCV20 with influenza or mRNA COVID-19 vaccines.Some patients are hesitant to receive vaccines, Are there side effects and contraindications to the vaccine?Local reactions are most common: pain/tenderness; swelling/induration (~20%); redness (~15%). Some people “baby” the arm for a couple of days. These typically resolve in 3–4 days; NSAIDs and warm compresses help.Systemic symptoms: fatigue, headache, myalgias/arthralgias, chills; fever ≥38°C is uncommon (

  AZ Bio Week & Life Sciences Innovation w/ Joan Koerber-Walker - AZ TRT S06 EP19 (281) 10-12-2025   Things We Learned This Week AZ Bio mission to improve life and bioscience, & make AZ a Top Ten Bioscience state AZ Bio Week 2025 - Oct. - 5 Days Talks, Events & Awards AZ Advances - nonprofit donation to biotech startups Aqualung Therapeutics is treating inflammation in the lungs, get people off ventilators & save lives Calviri is working on a Vaccine to PREVENT Cancer, currently largest animal clinical trial Anuncia Medical has a Re-Flow product to help drain fluid from the brain, treats Hydrocephalus     Guest: Joan Koerber-Walker President and CEO, AZBio - Arizona Bioindustry Association, Inc. Chairman, Opportunity Through Entrepreneurship Foundation   LKIN: https://www.linkedin.com/in/joankoerberwalker  www.azbio.org Bio: As President and CEO of AZBio, Joan Koerber-Walker works on behalf of the Arizona Bioscience and Medical Technology Industry to support the growth of the industry, its members and our community on the local and national level. Ms. Koerber-Walker is also a life science investor and has served on the boards of numerous for-profit and non-profit organizations. In the life science industry, Ms. Koerber-Walker serves as as Arizona's representative to the State Medical Technology Alliance (SMTA), a consortium of state and regional trade associations representing their local medical technology companies which she chaired in 2015 and  represents Arizona as a member of the Council of State Bioscience Associations (CSBA) and the Coalition of State Bioscience Institutes (CSBI). Active in the entrepreneurial and investment communities, she also serves as Chairman of the Board of the Opportunity Through Entrepreneurship Foundation which provides entrepreneurial education, mentoring and support to at-risk members of the community, on the Board of Advisors to CellTrust, Inc. which provides secure communication technology to the healthcare industry, and as Chairman of CorePurpose, Inc. which she founded in 2002. Ms. Koerber-Walker has been recognized as Executive of the Year by the Arizona Society of Association Executives, as a “Most Admired Leader” by the Phoenix Business Journal (2015),  in the pages of AZ Business Leaders (2013 thru 2020), Most Influential Women in Arizona Business (2014) and is a 2 time National Finalist for the Stevie Award which recognizes the work of women in business. Her past experience includes two years as the CEO of ASBA (the Arizona Small Business Association), service as a member of the Board of Trustees of the National Small Business Association in Washington D.C., President of the National Speakers Association/Arizona, Chair of the Board of Advisors to Parenting Arizona, the state's largest child abuse prevention organization, & much more.         AZBio:  Supporting Arizona's Life Science Industry for 19 Years (2003 – 2022) Learn more about Arizona's bioindustry: www.azbio.org | Facebook: AZBIO |Twitter: @AZBio @AZBioCEO We're part of a movement to create sustainable funding for life science innovation in Arizona. Learn more at www.AZAdvances.org  MOVING LIFE SCIENCE INNOVATIONS ALONG THE PATH FROM DISCOVERY TO DEVELOPMENT TO DELIVERY OUR VISION OF THE FUTURE: Arizona is a top-ten life science state. OUR MISSION: AZBio supports the needs of Arizona's growing life science ecosystem. The Arizona Bioindustry Association (AZBio) is a not-for-profit, 501(c)6 trade association supporting the growth of Arizona's life science sector. AZBio  Member Organizations in the fields of business, research and education, health care delivery, economic development, government, and other professions involved in the biosciences are the key drivers of the growth of Arizona's life science sector.  As the unified voice of our industry in Arizona, AZBio strives to make Arizona a place where bioscience organizations can grow and succeed.   AZBio works nationally and globally with the Advanced Medical Technology Association (AdvaMed), the Biotechnology Innovation Organization (BIO), the Medical Device Manufacturers Association (MDMA), the Pharmaceutical Research and Manufacturers of America (PhRMA), and leading patient advocacy organizations. Through these relationships, AZBio has access to information, contacts, resources, cost saving programs, and the global bioscience and medtech community.   Arizona's bioscience industry is growing rapidly and reached nearly 30,000 jobs spanning 2,160 business establishments in 2018. Industry employment has grown by 15 percent since 2016—twice the growth rate of the nation—with each of the five major subsectors adding jobs during the period. Arizona's universities conducted nearly $580 million in R&D activities in bioscience-related fields in 2018, fueled in part by steadily increasing NIH awards to Arizona institutions since 2016. Venture capital investments in Arizona bioscience companies increased in 2019, and during the 2016-19 period totaled $349 million. Arizona inventors have been awarded 2,178 bioscience-related patents since 2016, among the second quintile of states in patent activity.   Notes:   Seg 1   Biotech and life sciences industry in Arizona, has 3000 businesses and 36,000 employees. The economic impact in 2021 was $38.5 billion. AZ Bio would like to double, so by 2033, the impact would be $78 billion.   Examples of biotech companies in Arizona are Medtronic that makes medical devices, WL Gore, material sciences. Other companies in diagnostics, there are Sonoran Quest which does testing. This also Castle Bio Sciences, deals in cancer treatment. Some medicine companies are Bristol, Myers, and Calvari who deals in cancer drugs. Calvari is the bio science company of the year in 2024.   AZ Bio Science Week started in 2017. AZ Bio week starts Oct. 13 (2025) and has events daily from Monday to Friday.     Example of one of the many companies involved with AZ Bio week:   CND Life Sciences - CND's Syn-One Test® offers physicians and patients an accurate, convenient, evidence-based tool to help diagnose a synucleinopathy. And our mission has just begun.   NIH - National Institute of Health gives grants or funding to universities, hospitals and even companies for medical research.   Takes time to build a medical device type product, a few years to decades.   Government is an important partner, that provides financial support. Examples are Medicare research, workforce help, and tax breaks. Many organizations like this are publicly funded with government and university help.  $25 billion in funding over the last 20 years in Arizona in bio investment. Government funded $5 billion, that's from state and federal sales tax at a penny per. $112 million funding to universities in 2022. Combination of industry, government and philanthropy. Discovery phase - university helps develop the IP and research. Technology is spun out of the university to corporate development by companies. The AZ Board of Regents owns the patents. They license the patents to companies. Then you have regulatory.  Distribution of a product. Successful products are profitable. They have a royalty that pays to the company, the university and the government. Example of this was the University of Florida created Gatorade in the 1970s and still gets royalties today. Process takes 10 to 15 years, with hundreds of people involved. Clinical trials of any type of drug takes years.   Creation of the Covid vaccine was an outlier, as many people had Covid at the time so it was very easy to put together big study groups       Seg 2   Examples of newer companies in biotech field –   Neo clinical stage company dealing in heart health with aortic artery for the abdomen.   Another new company is prim dealing in MCT deficiency, compound growth and they are in clinical and testing stages.   Drugs get tested through computer models, and then on animals. Always have to worry about safety and ethics. FDA has very strict rules. You do not put people at risk, after monitor, during test and post monitoring. There's high-level quality control.       AZ Bio has members that are in the bioscience industry with current companies   AZ Advances is about bio startups in early stage companies It's a 501 C nonprofit charity that is funding, internships, and education   Patient is not only the client, but the purpose for why biotech companies exist     Neuralink Corp. is an American neurotechnology company that has developed as of 2024 implantable brain–computer interfaces. It was founded by Elon Musk and a team of eight scientists and engineers. Neuralink was launched in 2016 and first publicly reported in March 2017.   Neuralink's first human patient, Noland Arbaugh, is an Arizona native who received his implant in January 2024 at the Barrow Neurological Institute in Phoenix. He will appear at Arizona Bioscience Week 2025     https://www.azbio.org/azbw2025     Events Summary:   Monday - Women in Biotech Leading Women: Biotech & Beyond Join us for an evening of conversation and connections with our community's leading women as we kick off Arizona Bioscience Week in style!   Tuesday - Fundraising Fundraising Strategies for Life Science Startups  A compelling narrative is crucial when you are fundraising and communicating with life science investors.  This Life Science Nation (LSN) Global Fundraising Bootcamp covers topics related to executing a successful fundraise for your startup.      Wednesday – AZ Bio awards, philanthropy, entertainment, and AZ Advances The 21st Annual AZBio Awards & AZAdvances After Party Celebrate with the Educators, Researchers, and Organizations that are making life better for people in Arizona and around the world.  Join us at the Phoenix Convention Center as we honor the 2024 AZBio Award Winners. Hundreds of health innovators and business leaders will be celebrating at the 20th Annual AZBio Awards.   Thursday -  AZAdvances   AZ Advances Health Innovation Summit This exclusive event will bring together health innovation leaders to share how are moving Arizona forward as we make life better for the people we serve.   AZ Advances: Arizonans are advancing life changing and life saving innovations along the path from discovery to development to delivery. AZAdvances is developing the funding that will help advance health innovations in Arizona today and for generations to come.  Charitable donations to the AZAdvances fund at the Opportunity Through Entrepreneurship Foundation, an Arizona based 501c3 public charity, are a way to support the creation of tomorrow's medical innovations.    Friday - Voice of the Patient Patients are the reason we do what we do.  Join the conversation on life science innovation from the patient perspective.        Seg. 3 Best of AZ Bio clips:   AZ Bio & Life Sciences Innovation w/ Joan Koerber-Walker - BRT S04 EP10 (172) 3-5-2023   Guest: Joan Koerber-Walker President and CEO, AZBio - Arizona Bioindustry Association, Inc. Chairman, Opportunity Through Entrepreneurship Foundation   Full Show: HERE     Guest: Stan Miele President & CBO Aqualung Therapeutics Corp LKIN: HERE www.aqualungtherapeutics.com   Stan Miele Bio: A recognized global executive with success in sales, marketing and P&L leadership in the pharmaceutical/medical device and biotech industries. Mr. Miele was formally the Chief Commercial Officer at bioLytical Laboratories and Sucampo Pharmaceuticals Inc.  He was also President of Sucampo Pharma Americas for 6 years.   He was instrumental on some key licensing agreements for Sucampo, inclusive of the agreement with Abbott Japan, and also Takeda Pharmaceuticals (now Shire).  He is actively part of the team ensuring proper execution of clinical development, manufacturing, licensing, capital funding, alliances, and ensuring Aqualung meets all critical milestones.  He will be helping the company move toward accelerating the pipeline/platform technology and moving eNamptor™ toward commercialization.   Aqualung Therapeutics  Aqualung Therapeutics (ALT) is developing multi-pronged strategies to address the development of severe lung inflammation which is essential to the severity and outcomes of acute and chronic lung disorders such as acute lung injury, ventilator-induced lung injury (VILI), idiopathic pulmonary fibrosis, and pulmonary hypertension. Effective FDA-approved drugs are either currently unavailable or extraordinarily modest in their ability to modify disease progression. No drug is currently available that is preventive or curative. Aqualung's strategies, which include deployment of a human monoclonal antibody which targets a novel inflammatory mediator (nicotinamide phosphoribosyltransferase or NAMPT) will address the unmet need for novel, effective therapies for VILI, IPF, and pulmonary hypertension.   Full Show: HERE       Seg. 4 – Clips from:  Preventing Cancer with a Vaccine w/ Stephen Johnston of Calviri  - BRT S04 EP17 (179) 4-23-2023   Guest: Stephen Johnston Founding CEO, Calviri Inc.  LKIN: HERE https://calviri.com/   Bio: Chief Executive Officer & Chairman of the Board Stephen Albert Johnston is the inventor of the Calviri's central technologies. In addition to Calviri, he has been a founder of Eliance, Inc. (Macrogenics), Synbody Biotechnology and HealthTell, Inc. He is Director of the Arizona State University Biodesign Institute's Center for Innovations in Medicine and Professor in the School of Life Sciences. He has published almost 200 peer-reviewed papers and holds 45 patents. Prior to his appointment at ASU he was Professor and Director of the Center for Biomedical Inventions at UT-Southwestern Medical Center and Professor of Biology and Biomedical Engineering at Duke University. He is a member of the National Academy of Inventors. Dr. Johnston received his B.S. and Ph.D. degrees from the University of Wisconsin.     Calviri Inc.  We are determined to offer humanity a better life, free from cancer. While our goal is hugely ambitious, we are intensely driven to rid the planet of worry from cancer. Calviri's mission is to provide affordable products worldwide that will end deaths from cancer. We are a fully integrated healthcare company developing a broad spectrum of vaccines and companion diagnostics that prevent and treat cancer for those either at risk or diagnosed. We focus on using frameshift neoantigens derived from errors in RNA processing to provide pioneering products against cancer. The company is a spin out of the Biodesign Institute, Arizona State University, located in Phoenix, AZ. We have the largest dog vaccine trial in the world underway at three premier veterinary universities. The five-year trial will assess the performance of a preventative cancer vaccine.   Full Show: HERE       ReFlow to Help Treat Hydrocephalus w/ Elsa Abruzzo & Mark Geiger of Anuncia Medical - BRT S04 EP23 (186) 6-11-2023     Guest: Elsa Chi Abruzzo RAC, FRAPS – President Elsa Chi Abruzzo is a medical device executive, entrepreneur, and a founding member of Anuncia, Inc., Alcyone Therapeutics, Arthromeda, Inc. and Cygnus Regulatory. Elsa has a 30+ year successful product development, operations, regulatory, quality, and clinical track record in med tech Industries. Her experience includes leadership positions at Baxter, Cordis JNJ, CryoLife, Percutaneous Valve Technologies, AtriCure, InnerPulse, Merlin MD, Sapheon, and PTS Diagnostics. Elsa earned a BS in engineering from the University of Miami in Coral Gables, FL and is regulatory affairs certified and a Regulatory Affairs Professional Society Fellow, recognized for her leadership in Regulatory and Quality by MDDI.   https://anunciamedical.com/the-anuncia-story/#team https://www.linkedin.com/in/elsachiabruzzo/   https://anunciamedical.com/ About Anuncia Conceptualized in 2014 in collaboration with Boston Children's Hospital and spun out of Alcyone Therapeutics in 2018, Anuncia's patented portfolio of technologies are intended to provide peace-of-mind through innovation. Our core ReFlow™ technology uses a simple finger depression of a soft silicone dome located under the patient's scalp to produce a noninvasive, one-way flush of the patient's own CSF directed toward the ReFlow™ catheter to restore or increase CSF flow through a non-flowing shunt and potentially avoid emergency surgery.  Learn More     The name Anuncia comes from Panthera Uncia, the species name of the snow leopard. These animals live in mountainous regions of Asia and have been called by the World Wildlife Foundation “Guardians of the Headwaters” as they roam the headwater areas of the western basins. The origin of the word hydrocephalus comes from the Greek hudrokephalon, from hudro ‘water'+ kephalē ‘head'. The snow leopard, or Guardian of the Headwaters, is a symbol of Anuncia's dedication to improve daily quality of life for the millions of underserved patients with hydrocephalus and other CSF disorders, as well as their families, who suffer from the clinical, economic, and emotional burden of repeat revision brain surgery due to VP shunt occlusions.      Full Show: HERE           Best of Biotech from AZ Bio & Life Sciences to Jellatech: HERE   Biotech Shows: HERE   AZ Tech Council Shows:  https://brt-show.libsyn.com/size/5/?search=az+tech+council *Includes Best of AZ Tech Council show from 2/12/2023      ‘Best Of' Topic: https://brt-show.libsyn.com/category/Best+of+BRT      Thanks for Listening. Please Subscribe to the BRT Podcast.     AZ Tech Roundtable 2.0 with Matt Battaglia The show where Entrepreneurs, Top Executives, Founders, and Investors come to share insights about the future of business.  AZ TRT 2.0 looks at the new trends in business, & how classic industries are evolving.  Common Topics Discussed: Startups, Founders, Funds & Venture Capital, Business, Entrepreneurship, Biotech, Blockchain / Crypto, Executive Comp, Investing, Stocks, Real Estate + Alternative Investments, and more…    AZ TRT Podcast Home Page: http://aztrtshow.com/ ‘Best Of' AZ TRT Podcast: Click Here Podcast on Google: Click Here Podcast on Spotify: Click Here                    More Info: https://www.economicknight.com/azpodcast/ KFNX Info: https://1100kfnx.com/weekend-featured-shows/     Disclaimer: The views and opinions expressed in this program are those of the Hosts, Guests and Speakers, and do not necessarily reflect the views or positions of any entities they represent (or affiliates, members, managers, employees or partners), or any Station, Podcast Platform, Website or Social Media that this show may air on. All information provided is for educational and entertainment purposes. Nothing said on this program should be considered advice or recommendations in: business, legal, real estate, crypto, tax accounting, investment, etc. Always seek the advice of a professional in all business ventures, including but not limited to: investments, tax, loans, legal, accounting, real estate, crypto, contracts, sales, marketing, other business arrangements, etc.

The Glymphatic System is the brain's newly discovered waste clearance system. It acts like a highly specialized lymphatic system for the central nervous system, flushing out toxins and metabolic waste, including proteins like amyloid-beta, which are associated with Alzheimer's disease. The glymphatic system is most active during sleep and is powered by the rhythmic movement of cerebrospinal fluid (CSF).Chiropractic care, particularly through its influence on the spine and nervous system, is theorized to have a direct impact on the function and efficiency of this vital brain cleansing process.1. Chiropractic Care and CSF FlowChiropractic adjustments aim to restore proper motion and alignment to the vertebrae, particularly in the upper neck (cervical spine). This area is crucial because:Dural Tension: Misalignment in the upper neck (subluxations) can create tension in the surrounding connective tissues, which are continuous with the dura mater (the membrane covering the brain and spinal cord). This tension can mechanically impede the optimal flow of Cerebrospinal Fluid (CSF).Optimal Fluid Dynamics: Since the glymphatic system relies on the pulsatile flow of CSF to exchange fluid and clear waste, ensuring the craniocervical junction (where the head meets the neck) is functioning optimally is essential. By reducing tension and restoring alignment, chiropractic adjustments may help maintain the natural, unimpeded "pumping" action required for efficient CSF and, thus, glymphatic movement.2. Impact on Autonomic Nervous System BalanceChiropractic care is well-known for its ability to influence the Autonomic Nervous System (ANS), which controls involuntary bodily functions.The Vagus Nerve: The upper cervical spine is close to the brainstem and key areas of the nervous system, including the vagus nerve. Adjusting this area can help shift the ANS from a state of "fight or flight" (sympathetic dominance) toward a state of "rest and digest" (parasympathetic dominance).Better Sleep, Better Clearance: The glymphatic system is most active during deep, restorative sleep. By promoting a parasympathetic state, chiropractic adjustments can help patients achieve deeper, higher-quality sleep, directly enhancing the hours dedicated to crucial brain detoxification.3. Benefits for Overall Brain HealthBy optimizing CSF and supporting the nervous system, the benefits of combining chiroThis podcast welcomes your feedback here are several ways to reach out to me. If you have a topic you would like to hear about send me a message. I appreciate your listening. Dr. Brian Mc Kayhttps://twitter.com/DarienChiro/https://www.facebook.com/ChiropractorBrianMckayhttps://chiropractor-darien-dr-brian-mckay.business.sitehttps://podcasts.apple.com/us/podcast/not-just-chiropractor-for-stamford-darien-norwalk-new/id1503674397?uo=4Core Health Darien-Dr.Brian Mc Kay 551 Post RoadDarien CT 06820203-656-363641.0833695 -73.46652073GMP+87 Darien, Connecticuthttps://youtu.be/WpA__dDF0O041.0834196 -73.46423349999999https://darienchiropractor.comhttps://darienchiropractor.com/darien/darien-ct-understanding-pain/Find us on Social Mediahttps://chiropractor-darien-dr-brian-mckay.business.site https://www.youtube.com/channel/UCNHc0Hn85Iiet56oGUpX8rwhttps://docs.google.com/spreadsheets/d/1nJ9wlvg2Tne8257paDkkIBEyIz-oZZYy/edit#gid=517721981https://goo.gl/maps/js6hGWvcwHKBGCZ88https://www.youtube.com/my_videos?o=Uhttps://www.linkedin.com/in/darienchiropractorhttps://www.facebook.com/ChiropractorBrianMckayhttps://sites.google.com/view/corehealthdarien/https://sites.google.com/view/corehealthdarien/home

As part of our ongoing collaboration with Central Square Foundation, we are here with the third episode of our five part series where we talk about public disclosure of school learning quality data.Usually, when parents assess schools for their children, they focus on non-academic factors like infrastructure and school facilities. But they do not have access to information regarding the most important factor that is student learning quality. The National Education Policy 2020 places a strong emphasis on public disclosure of school performance. To understand how is this reform is being implemented, we'll be joined by two guests who have been working hard towards bringing this change, Kapil Khurana, Associate Director for School Governance at CSF and A.K. Modh Patel, Additional Director, GCERT, Gujarat who is leading Gujarat's effort to disclose school learning quality data through the School Quality Assessment and Assurance Framework (SQAAF).Hosted and produced by Niharika NandaEdited and mixed by Suresh PawarLink to the first and second episode of our series with CSF:Episode 1Episode 2

Celebrate hunting and fishing traditions while exploring the latest conservation victories and outdoor legislative battles.   Hunting and fishing aren't just pastimes—they're the backbone of conservation in America. In this episode of Sportsmen's Voice, we dive into the significance of National Hunting and Fishing Day and the powerful reminder it brings about the role sportsmen play in wildlife management. You'll hear why state proclamations and bipartisan support matter more than ever for protecting our sporting heritage.   We break down Michigan's critical hunting license restructuring and what it means for the future of conservation funding. From there, we highlight the leadership of CSF's Senior Vice President, Taylor Schmitz and his recognition for advancing pro-sportsman policies, giving listeners an inside look at how strong advocacy shapes the outdoor world.   The discussion also previews the upcoming 22nd Annual NASC Sportsman-Legislator Summit, a gathering where the future of hunting and fishing legislation takes center stage. And if you're dreaming about big game, don't miss our look at expanding elk hunting opportunities in Alaska, proof that smart wildlife management benefits both hunters and ecosystems.   Whether you're a seasoned waterfowl hunter, an elk enthusiast, or a weekend angler, this episode equips you with the knowledge and context to stay informed, stay engaged, and keep our outdoor traditions alive.   Get the FREE Sportsmen's Voice e-publication in your inbox every Monday: www.congressionalsportsmen.org/newsletter   Follow The Sportsmen's Voice wherever you get your podcasts: https://podfollow.com/1705085498  Learn more about your ad choices. Visit megaphone.fm/adchoices

What if we could detect Alzheimer's disease before the first memory fades? In this powerful episode of Med Tech Gurus, Dr. Maria-Magdalena Patru, MD, PhD—who leads the neurology medical team at Roche Diagnostics US—explains how early diagnosis is being radically transformed through CSF and blood-based biomarker innovations. With Alzheimer's affecting over 7 million Americans, Dr. Patru outlines how new guidelines, improved reimbursement, and diagnostic advances are helping clinicians identify the disease earlier—when treatments can still preserve cognition. She also shares how her personal connection to Alzheimer's drives her mission and offers advice to innovators navigating regulatory and clinical pathways. If you're building diagnostics or working on access-to-care challenges, this is a must-listen. https://www.medtechgurus.com https://diagnostics.roche.com/us/en/products/product-category/neurology/alzheimers-disease.html  

Normal pressure hydrocephalus, where fluid called CSF builds up in the brain, is fairly common with aging, and has been treated with something called a shunt that diverts the excess fluid to the abdomen. Now a study by Mark Luciano, … Shunts do work for a condition where fluid builds up in the brain, Elizabeth Tracey reports Read More »

The singer Billy Joel recently announced he has normal pressure hydrocephalus, or NPH, a condition where fluid builds up in the brain and may cause a host of problems. Mark Luciano, a neurosurgeon and head of the CSF disorders group … Fluid in the brain known as hydrocephalus is fairly common with aging, Elizabeth Tracey reports Read More »

As part of our ongoing collaboration with Central Square Foundation, we are excited to bring to you the second episode of our five part series where we talk about the transformative journey of the NIPUN Bharat Mission.It has been four years since the launch of the Mission and for the first time in two decades we are seeing learning improvements among children. In this episode, we explore how the program has made significant strides in improving literacy and numeracy levels of students in Grades 1-3 across the country. And to get a deeper insight into the progress behind this Mission, we're joined by Parthajeet Das, Project Director for FLN, at CSF and Sambhrant Srivastava, Associate Director for FLN, who have been closely working with state departments of education of Haryana, Madhya Pradesh,Uttar Pradesh, Telangana, Assam, Punjab and Odisha, among other states.Hosted and produced by Niharika NandaEdited and mixed by Suresh PawarLink to the first episode of our series with CSF:Episode 2

Vinod Karate is Project Director for State Reform at the Central Square Foundation where he helps drive India's landmark NIPUN Bharat Mission to ensure every child can read, write, and count by age ten. From an early career in investment banking to shaping one of the world's largest foundational learning reforms, Vinod's journey bridges sharp strategy with deep community engagement. In this episode, Vinod shares how India is rethinking the very foundations of schooling and how CSF partners with states to design and scale reforms that align with India's NIPUN Bharat goals. He unpacks CSF's three-phase approach to state reform: strengthening teacher capacity, redesigning governance around learning outcomes, and building political and administrative coalitions, which helps make large-scale change possible. Drawing on his experience in Uttar Pradesh, Madhya Pradesh, and Haryana, Vinod illustrates how reform really takes root on the ground. He explains how structured pedagogy, sustained teacher mentoring, and real-time data and assessment can translate policy into daily classroom practice, and how seizing windows of political alignment, unlocking budgets, and shifting decision-making from state capitals to districts ensures that change is owned and sustained at the local level. Grounded in evidence, this episode offers a clear, actionable roadmap for strengthening foundational learning and creating education systems that sustain reform and deliver lasting results for every child.

In this episode of the Trauma and Burn Anesthesia Series, we examine traumatic brain injury, the leading cause of trauma-related death in the U.S., affecting over a million people annually and leaving millions with long-term disability. We discuss the importance of the Glasgow Coma Scale, the types of primary injuries such as subdural, epidural, and intraparenchymal hematomas as well as diffuse axonal injury, and how these lead to increased intracranial pressure, herniation, and neurological decline. We explore secondary brain injury from hypotension, hypoxemia, hypercapnia, and hyperthermia, emphasizing the need to maintain adequate perfusion and oxygenation while balancing damage control resuscitation. Key management strategies include hyperosmolar therapy, ICP monitoring, CSF drainage, hyperventilation, mannitol use, steroids, seizure and infection prophylaxis, and cautious fluid therapy. We also cover practical intraoperative considerations, avoiding excessive anesthetics, carefully managing CSF drains, and adjusting ventilation, while highlighting the added complexity when TBI patients also present with massive hemorrhage.Want to learn more? Create a FREE account at www.atomicanesthesia.com⚛️ CONNECT:

Learn about facial injury red flags, CSF identification, EAP essentials, and return-to-play guidelines for athletes from Dr. Rehal Bhojani. Q: What are the red flags for hematomas? A: Protocols from SCAT6 and other guidelines for hematomas or hemorrhages emphasize watching for loss of consciousness (LOC), altered mental status, and vomiting. Quickly identify these signs to avoid missing late concussions or other critical issues. Ensure the mechanism of injury (MOI) aligns with the trauma; diagnosis is challenging if it doesn't. Q: How can CSF be identified, and what is the "halo sign" red flag? A: The halo sign, also known as the ring sign, remains the best indicator for identifying cerebrospinal fluid (CSF). CSF is distinct: it has a clear-to-mucous color, is super thin, lighter than water, and does not mix with other fluids. For instance, a soccer player initially diagnosed with a concussion showed a bloody nose and consistent halo sign post-game, necessitating immediate emergency room referral. Q: What essential elements should be added to an Emergency Action Plan (EAP)? A: EAPs are becoming more comprehensive, focusing on three key areas. First, ensure resource accessibility by including contacts for ENTs, dentists, and eye doctors. Second, review the EAP regularly, two to three times a year, rather than just annually, using past injury knowledge to proactively improve it. Third, if using AI to draft EAPs, meticulously verify all listed resources. Q: What items should be included in kits for eye and tooth injuries? A: For eye and tooth injuries, kits should include 4x4 gauzes, an otoscope, a "Save a Tooth" system, eyedrops, nasal tampons, and Afrin. Physician-approved medications should also be added, along with an ENT kit, which is available online. Q: What are the risks and benefits of athletic trainers performing sutures on the field? A: On-field suturing depends on the location and type of laceration, with the cause (e.g., metal object) being crucial due to potential tetanus considerations. Athletes often return to play the same day with sutures. For facial lacerations, specific types and sizes of sutures are used, but caution is advised near the eye. Eyebrows and the skull are generally suitable for suturing if no underlying fracture exists. Control bleeding and inform athletes of the risks associated with playing with sutures; safety is paramount. Q: When can athletes return to play after tooth injuries? A: For primary (baby) teeth, if no secondary tooth injury is suspected, return to play (RTP) is generally straightforward. However, secondary tooth injuries involving complex factors can lead to lasting effects. It is important to document whether the injury involves primary versus permanent teeth. For younger children, involve parents to understand the mechanism of injury and the potential for future crown and root fractures. Q: What current sports medicine trends should recent graduates be aware of or learn in the classroom? A: Sports medicine is constantly evolving, with increased pressure for accurate decision-making. Recent graduates need to be proficient in current literature and comfortable with shared decision-making and escalating care. As athletic trainers often serve as primary sports medicine providers, they require broad skills across various domains. Q: How can these emerging sports medicine competencies be effectively taught? A: Teaching these competencies is challenging due to the need for comprehensive exposure. Educational methods vary by setting, and the field has expanded significantly. Training provides a broad scope, so it's important not to be narrow-minded. Past experiences remain relevant, and post-training, continuous reading and skill refinement are crucial. In a controlled educational environment, students should learn as much as possible, as quickly as possible, to prepare for real-world practice.

Commercial space is a growing industry, and the U.S. government is looking for ways to build capabilities, support private industry, and increase competition. Organizations like Satellite Industry Association (SIA) and Commercial Space Federation (CSF) are working to ensure their members have a voice when it comes to government policy making and strategies for maintaining U.S. leadership in space.  Join Audrey Allison, Sr Policy Analyst CSPS, Mr. David Cavossa, President CSF, and Mr. Tom Stroup, President SIA as they discuss some of the most important challenges, recent White House decisions, safety and sustainability, the EU Space Act, international decision-making, competition with China, and more.  This episode is part of the Going Faster Series that discusses various facets of speed, agility, innovation, and rapid deployment in national security, civil, and commercial space.    The Space Policy Show is produced by The Aerospace Corporation's Center for Space Policy and Strategy. It is a virtual series covering a broad set of topics that span across the space enterprise. CSPS brings together experts from within Aerospace, the government, academia, business, nonprofits, and the national labs. The show and their podcasts are an opportunity to learn about and to stay engaged with the larger space policy community. Subscribe to our YouTube channel to watch all episodes!

Hunting, fishing, and outdoor access face new legislative battles—here's what every sportsman should know.   In this episode, the Congressional Sportsmen's Foundation team breaks down the latest updates shaping hunting, fishing, and outdoor conservation policy at both the state and federal levels.   First, Taylor Schmitz dives into recent public lands legislation, explaining how new proposals could impact hunters, anglers, and outdoor recreation. He highlights the fight to remove harmful language from a reconciliation package, stresses the dangers of selling federal public lands, and shares why community engagement is key to protecting access for future generations.   Next, Chris Horton covers Q3 updates in the fisheries and boating sector, including the reauthorization of the Sport Fish Restoration and Boating Trust Fund and the latest movement on the SHARKED Act. We discuss how shark depredation is affecting saltwater anglers, why conservation strategies must balance fisheries management with angler access, and how visual storytelling is being used to highlight marine conservation issues.   Finally, John Culclasure brings an update on federal and state forest policy, unpacking the challenges of wildfire threats, roadless rule restrictions, and timber sales. He shares highlights from the American Forest Congress, emphasizes the importance of stakeholder collaboration in active forest management, and explains what new legislation could mean for hunters, anglers, and forest health nationwide.   Key Takeaways for Hunters, Anglers, and Outdoor Enthusiasts: Selling federal public lands can create long-term problems for outdoor access if not done with careful analysis and forethought. The Farm Bill and upcoming federal funding deadlines could reshape conservation priorities. The Sport Fish Restoration and Boating Trust Fund is vital for fisheries and boating programs. Shark depredation is a growing problem for saltwater anglers. Forest management legislation, including the Fix Our Forests Act, could impact wildfire prevention. Collaboration between government, industry, and conservation groups is essential for sustainable outdoor policy.   Whether you're passionate about public lands, fisheries, or forestry, this episode will keep you informed on the policy debates shaping the future of hunting, fishing, and outdoor recreation in America.   Get the FREE Sportsmen's Voice e-publication in your inbox every Monday: www.congressionalsportsmen.org/newsletter                Sign up for FREE legislative tracking through CSF's Tracking the Capitols tool: www.congressionalsportsmen.org/tracking-the-capitols/   Get the FREE Sportsmen's Voice e-publication in your inbox every Monday: www.congressionalsportsmen.org/newsletter                Sign up for FREE legislative tracking through CSF's Tracking the Capitols tool: www.congressionalsportsmen.org/tracking-the-capitols/ Learn more about your ad choices. Visit megaphone.fm/adchoices

In the 5th anniversary year of the National Education Policy 2020, the NIPUN Bharat Mission, which was launched a year later- with its emphasis on foundational learning for all children in Grades 1-3 was adopted by many states in the form of their own programmes. Uttar Pradesh was one of the early adopters of an FLN programme across more than 1.1 lakh FLN-grade schools. UP is currently achieving 68% proficiency in Language and 64% proficiency in Math as part of its FLN programme.Starting with today's episode, on the occasion of Teachers' Day, The Indian Express in association with Central Square Foundation brings to you a five part series, where we will discuss the importance of Foundational Literacy with experts of the field.And to learn how UP reached where it is today, we are joined by Vinod Karate, Sr. Project Director, FLN Reforms, CSF and Vaibhav Limaye, who has been embedded with the Samagra Shiksha department in Lucknow, to understand how the change is taking shape.Hosted and produced by Niharika NandaEdited and mixed by Suresh Pawar

Discover the latest hunting, fishing, and conservation updates shaping outdoor opportunities across the country. In this episode of The Sportsmen's Voice Roundup, we break down major updates in hunting, fishing, and conservation news that matter to every outdoorsman. The U.S. Fish and Wildlife Service has expanded hunting and fishing access across 11 states, opening up new opportunities for sportsmen nationwide. We also cover New York's decision to officially include crossbows in its archery season—a win that hunters and conservationists have pushed for over 15 years. Meanwhile, Louisiana continues to see landmark legislative progress, from expanding black bear hunting opportunities to revitalizing historic waterfowl hunting areas. These bipartisan victories demonstrate how strong collaboration among hunters, anglers, and conservation groups is driving meaningful change. We also dive into the importance of modern muzzleloading technology, the role of updated regulations in creating better hunting practices, and how expanded outdoor opportunities fuel critical conservation funding. If you're passionate about hunting, fishing, and protecting America's outdoor heritage, this episode delivers the must-know updates shaping the future of our sports.   Get the FREE Sportsmen's Voice e-publication in your inbox every Monday: www.congressionalsportsmen.org/newsletter   Sign up for FREE legislative tracking through CSF's Tracking the Capitols tool: www.congressionalsportsmen.org/tracking-the-capitols/   Follow The Sportsmen's Voice wherever you get your podcasts: https://podfollow.com/1705085498  Learn more about your ad choices. Visit megaphone.fm/adchoices

Explore new hunting and fishing laws shaping access, conservation, and the future of outdoor sports. In this week's Sportsmen's Voice podcast roundup, we dive into the latest news impacting hunters, anglers, and outdoor enthusiasts nationwide. We cover a groundbreaking executive order designed to expand saltwater fishing access, along with Montana's finalized 2025–2026 hunting and fishing regulations. The episode highlights Hunting Heritage Protection Acts in the Northeast, ensuring public access and preserving our outdoor traditions. We also examine a new two-tier program that lowers barriers for beginner duck hunters, the growing push to bring hunter education into schools, and the economic impact of recreational fishing across the U.S. Whether you're passionate about hunting conservation, fishing opportunities, or the future of outdoor access, this episode is packed with updates every sportsman needs to know. Takeaways New executive order expands saltwater fishing opportunities for recreational anglers. Montana finalizes statewide wildlife and fisheries regulations for 2025–2026. Hunting Heritage Protection Acts safeguard public access for hunters and anglers. Two-tier duck hunting program makes it easier for new waterfowl hunters to get started. Hunter education in schools helps recruit and train the next generation of sportsmen. Protecting hunting and fishing access on public lands remains a top priority. Recreational fishing continues to deliver massive economic benefits to local communities. Stronger collaboration between agencies, conservation groups, and sportsmen is essential.   Get the FREE Sportsmen's Voice e-publication in your inbox every Monday: www.congressionalsportsmen.org/newsletter   Sign up for FREE legislative tracking through CSF's Tracking the Capitols tool: www.congressionalsportsmen.org/tracking-the-capitols/   Follow The Sportsmen's Voice wherever you get your podcasts: https://podfollow.com/1705085498  Learn more about your ad choices. Visit megaphone.fm/adchoices

Discover how the Sport Fish Restoration Fund fuels fishing fisheries conservation across America. For 75 years, the Sport Fish Restoration and Boating Trust Fund has been the backbone of fishing and conservation in the U.S. This episode explores how the Fund works, why it matters, and what's needed to ensure its future. Experts break down the mechanics of the fund—how excise taxes on fishing gear, tackle, boats, and fuel are transformed into billions of dollars for state-level conservation programs. We dig into how these dollars support habitat restoration, fish stocking, boating access, and R3 initiatives that bring new  anglers into the outdoors. The conversation also tackles pressing challenges, from legislative threats in Washington to the ongoing need for education and advocacy with policymakers. Listeners will hear why partnerships between state agencies, manufacturers, and conservation groups are critical for keeping the fund strong. Whether you're an avid angler or other conservation-minded outdoorsman, this discussion reveals the economic, cultural, and environmental impact of a program that has shaped the outdoor heritage we enjoy today. Takeaways: The Sport Fish Restoration Fund remains a cornerstone of conservation in the U.S. Funding comes from excise taxes on fishing equipment and motorboat fuel. R3 programs are vital for recruiting new anglers. Fishing contributes billions to the American economy annually. The 75th anniversary is a chance to celebrate and advocate for the future of conservation funding.   Get the FREE Sportsmen's Voice e-publication in your inbox every Monday: www.congressionalsportsmen.org/newsletter                Sign up for FREE legislative tracking through CSF's Tracking the Capitols tool: www.congressionalsportsmen.org/tracking-the-capitols/ Learn more about your ad choices. Visit megaphone.fm/adchoices

From Florida's first black bear hunt in a decade to new pheasant camps in the Plains, Fred Bird breaks down your weekly outdoor news and the biggest stories in hunting, fishing, and conservation across the nation.  We kick off with Florida's black bear hunt returning for the first time in 10 years. The Florida Fish and Wildlife Commission voted unanimously to reinstate a highly regulated season with limited tags and fair-chase methods, marking a major win for science-based wildlife management. In Delaware, Governor Matt Meyer officially joins the Governor's Sportsmen's Caucus, strengthening bipartisan support for hunting, angling, and outdoor heritage at the state and national level. Meanwhile, Western states face conservation funding challenges, with agencies in Washington and Oregon navigating historic budget shortfalls that could impact hatcheries, pheasant programs, and wildlife access. On a brighter note, new hunter opportunities are launching in the Great Plains, including South Dakota's first youth deer camp and Nebraska's ladies pheasant hunt program—designed to mentor and recruit the next generation of outdoorsmen and women. Finally, we highlight a prescribed fire project in Kentucky's Daniel Boone National Forest, a critical initiative to restore white oak habitat, strengthen wildlife populations, and support industries like bourbon and wood products. Whether it's hunting policy, fishing access, or other conservation programs, The Sportsmen's Voice is your trusted source for outdoor news that matters.   Get the FREE Sportsmen's Voice e-publication in your inbox every Monday: www.congressionalsportsmen.org/newsletter   Sign up for FREE legislative tracking through CSF's Tracking the Capitols tool: www.congressionalsportsmen.org/tracking-the-capitols/   Follow The Sportsmen's Voice wherever you get your podcasts: https://podfollow.com/1705085498  Learn more about your ad choices. Visit megaphone.fm/adchoices

Multiple system atrophy is a rare, sporadic, adult-onset, progressive, and fatal neurodegenerative disease. Accurate and early diagnosis remains challenging because it presents with a variable combination of symptoms across the autonomic, extrapyramidal, cerebellar, and pyramidal systems. Advances in brain imaging, molecular biomarker research, and efforts to develop disease-modifying agents have shown promise to improve diagnosis and treatment. In this episode, Casey Albin, MD speaks with Tao Xie, MD, PhD, author of the article “Multiple System Atrophy” in the Continuum® August 2025 Movement Disorders issue. Dr. Albin is a Continuum® Audio interviewer, associate editor of media engagement, and an assistant professor of neurology and neurosurgery at Emory University School of Medicine in Atlanta, Georgia. Dr. Xie is director of the Movement Disorder Program, chief of the Neurodegenerative Disease Section in the department of neurology at the University of Chicago Medicine in Chicago, Illinois. Additional Resources Read the article: Multiple System Atrophy Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @caseyalbin Full episode transcript available here Dr. Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. Dr Albin: Hello everyone, this is Dr Casey Albin. Today I'm interviewing Dr Tao Xie about his article on diagnosis and management of multiple system atrophy, which appears in the August 2025 Continuum issue on movement disorders. Welcome to the podcast, and please introduce yourself to our audience. Dr Xie: Thank you so much, Dr Albin. My name is Tao Xie, and sometimes people also call me Tao Z. I'm a mood disorder neurologist, professor of neurology at the University of Chicago. I'm also in charge of the mood disorder program here, and I'm the section chief in the neurodegenerative disease in the Department of Neurology at the University of Chicago Medicine. Thank you for having me, Dr Albin and Dr Okun and the American Academy of Neurology. This is a great honor and pleasure to be involved in this education session. Dr Albin: We are delighted to have you, and thank you so much for the thoughtful approach to the diagnosis and management. I really want to encourage our listeners to check out this article. You know, one of the things that you emphasize is multiple system atrophy is a fairly rare condition. And I suspect that clinicians and trainees who even have a fair amount of exposure to movement disorders may not have encountered that many cases. And so, I was hoping that you could just start us off and walk us through what defines multiple system atrophy, and then maybe a little bit about how it's different from some of the more commonly encountered movement disorders. Dr Xie: This is a really good question, Dr Albin. Indeed, MSA---multisystem atrophy----is a rare disease. It is sporadic, adult-onset, progressive, fatal neurodegenerative disease. By the name MSA, multisystem atrophy. Clinically, it will present with multiple symptoms and signs involving multiple systems, including symptoms of autonomic dysfunction and symptoms of parkinsonism, which is polyresponsive to the levodopa treatment; and the symptom of cerebellar ataxia, and symptom of spasticity and other motor and nonmotor symptoms. And you may be wondering, what is the cause- underlying cause of these symptoms? Anatomically, we can find the area in the basal ganglia striatonigral system, particularly in the putamen and also in the cerebellar pontine inferior, all of the nuclear area and the specific area involved in the autonomic system in the brain stem and spinal cord: all become smaller. We call it atrophy. Because of the atrophy in this area, they are responsible for the symptom of parkinsonism if it is involved in the putamen and the cerebral ataxia, if it's involved in the pons and cerebral peduncle and the cerebellum. And all other area, if it's involved in the autonomic system can cause autonomic symptoms as well. So that's why we call it multisystem atrophy. And then what's the underlying cellular and subcellular pathological, a hallmark that is in fact caused by misfolded alpha-synuclein aggregate in the oligodontia site known as GCI---glial cytoplasmic increasing bodies---in the cells, and sometimes it can also be found in the neuronal cell as well in those areas, as mentioned, which causes the symptom. But clinically, the patient may not present all the symptoms at the same time. So, based on the predominant clinical symptom, if it's mainly levodopa, polyresponsive parkinsonism, then we call it MSAP. If it's mainly cerebellar ataxia, then we call it MSAC. But whether we call it MSP or MSC, they all got to have autonomic dysfunction. And also as the disease progresses, they can also present both phenotypes together. We call that mixed cerebellar ataxia and parkinsonism in the advanced stage of the disease. So, it is really a complicated disease. The complexity and the similarity to other mood disorders, including parkinsonism and the cerebellar ataxia, make it really difficult sometimes, particularly at the early stages of disease, to differentiate one from the other. So, that was challenging not only for other professionals, general neurologists and even for some movement disorder specialists, that could be difficult particularly if you aim to make an accurate and early diagnosis. Dr Albin: Absolutely. That is such a wealth of knowledge here. And I'm going to distill it just a little bit just to make sure that I understand this right. There is alpha-synuclein depositions, and it's really more widespread than one would see maybe in just Parkinson's disease. And with this, you are having patients present with maybe one of two subtypes of their clinical manifestations, either with a Parkinson's-predominant movement disorder pattern or a cerebellar ataxia type movement disorder pattern. Or maybe even mixed, which really, you know, we have to make things quite complicated, but they are all unified and having this shared importance of autonomic features to the diagnosis. Have I got that all sort of correct? Dr Xie: Correct. You really summarize well. Dr Albin: Fantastic. I mean, this is quite a complicated disease. I would pose to you sort of a case, and I imagine this is quite common to what you see in your clinic. And let's say, you know, a seventy-year-old woman comes to your clinic because she has had rigidity and poor balance. And she's had several falls already, almost always from ground level. And her family tells you she's quite woozy whenever she gets up from the chair and she tends to kind of fall over. But they noticed that she's been stiff,and they've actually brought her to their primary care doctor and he thought that she had Parkinson's disease. So, she started levodopa, but they're coming to you because they think that she probably needs a higher dose. It's just not working out very well for her. So how would you sort of take that history and sort of comb through some of the features that might make you more concerned that the patient actually has undiagnosed multiple systems atrophy? Dr Xie: This is a great case, because we oftentimes can encounter similar cases like this in the clinic. First of all, based on the history you described, it sounds like an atypical parkinsonism based on the slowness, rigidity, stiffness; and particularly the early onset of falls, which is very unusual for typical Parkinson disease. It occurs too early. If its loss of balance, postural instability, and fall occurred within three years of disease onset---usually the motor symptom onset---then it raises a red flag to suspect this must be some atypical Parkinson disorders, including multiple system atrophy. Particularly, pou also mentioned that the patient is poorly responsive to their levodopa therapy, which is very unusual because for Parkinson disease, idiopathic Parkinson disease, we typically expect patients would have a great response to the levodopa, particularly in the first 5 to 7 years. So to put it all together, this could be atypical parkinsonism, and I could not rule out the possibility of MSA. Then I need to check more about other symptoms including autonomic dysfunction, such as orthostatic hypertension, which is a blood pressure drop when the patient stands up from a lying-down position, or other autonomic dysfunctions such as urinary incontinence or severe urinary retention. So, in the meantime, I also have to put the other atypical Parkinson disorder on the differential diagnosis, such as PSP---progressive supranuclear palsy---and the DLBD---dementia with Lewy body disease.---Bear this in mind. So, I want to get more history and more thorough bedside assessment to rule in or rule out my diagnosis and differential diagnosis. Dr Albin: That's super helpful. So, looking for early falls, the prominence of autonomic dysfunction, and then that poor levodopa responsiveness while continuing to sort of keep a very broad differential diagnosis? Dr Xie: Correct. Dr Albin: One of the things that I just have to ask, because I so taken by this, is that you say in the article that some of these patients actually have preservation of smell. In medical school, we always learn that our Parkinson's disease patients kind of had that early loss of smell. Do you find that to be clinically relevant? Is that- does that anecdotally help? Dr Xie: This is a very interesting point because we know that the loss of smelling function is a risk effect, a prodromal effect, for the future development of Parkinson disease. But it is not the case for MSA. Strange enough, based on the literature and the studies, it is not common for the patient with MSA to present with anosmia. Some of the patients may have mild to moderate hyposmia, but not to the degree of anosmia. So, this is why even in the more recent diagnosis criteria, the MDS criteria published 2022, it even put the presence of anosmia in the exclusion criteria. So, highlight the importance of the smell function, which is well-preserved for the majority in MSA, into that category. So, this is a really interesting point and very important for us, particularly clinicians, to know the difference in the hyposmia, anosmia between the- we call it the PD, and the dementia Lewy bodies versus MSA. Dr Albin: Fascinating. And just such a cool little tidbit to take with us. So, the family, you know, you're talking to them and they say, oh yes, she has had several fainting episodes and we keep taking her to the primary care doctor because she's had urinary incontinence, and they thought maybe she had urinary tract infections. We've been dealing with that. And you're sort of thinking, hm, this is all kind of coming together, but I imagine it is still quite difficult to make this diagnosis based on history and physical alone. Walk our listeners through sort of how you're using MRI and DAT scan and maybe even some other biomarkers to help sort of solidify that diagnosis. Dr Xie: Yeah, that's a wonderful question. Yeah. First of all, UTI is very common for patients with MSA because of urinary retention, which puts them into a high risk of developing frequent UTI. That, for some patients, could be the very initial presentation of symptoms. In this case, if we check, we say UTI is not present or UTI is present but we treat it, then we check the blood pressure and we do find also hypertension---according to new diagnosis criteria, starting drop is 20mm mercury, but that's- the blood pressure drop is ten within three minutes. And also, in the meantime the patients present persistent urinary incontinence even after UTI was treated. And then the suspicion for MS is really high right at this point. But if you want increased certainty and a comfortable level on your diagnosis, then we also need to look at the brain MRI mark. This is a required according to the most recent MDS diagnosis criteria. The presence of the MRI marker typical for MSA is needed for the diagnosis of clinically established MSA, which holds the highest specificity in the clinical diagnosis. So then, we have- we're back to your question. We do need to look at the brain MRI to see whether evidence suggestive of atrophy around the putamen area, around the cerebellar pontine inferior olive area, is present or not. Dr Albin: Absolutely. That's super helpful. And I think clinicians will really take that to sort of helping to build a case and maybe recognizing some of this atypical Parkinson's disease as a different disease entity. Are there any other biomarkers in the pipeline that you're excited about that may give us even more clarity on this diagnosis? Dr Xie: Oh, yeah. This is a very exciting area. In terms of biomarker for the brain imaging, particularly brain MRI, in fact, today there's a landmark paper just published in the Java Neurology using AI, artificial intelligence or machine learning aid, diagnoses a patient with parkinsonism including Parkinson's disease, MSA, and PSP, with very high diagnostic accuracy ranging from 96% to 98%. And some of the cases even were standard for autopsy, with pathological verification at a very high accurate rate of 93.9%. This is quite amazing and can really open new diagnosis tools for us to diagnose this difficult disease; not only in an area with a bunch of mood disorder experts, but also in the rural area, in the area really in need of mood disorder experts. They can provide tremendous help to provide accurate, early diagnosis. Dr Albin: That's fantastic and I love that, increasing the access to this accurate diagnosis. What can't artificial intelligence do for us? That's just incredible. Dr Xie: And also, you know, this is just one example of how the brain biomarker can help us. Theres other---a fluid biomarker, molecular diagnostic tools, is also available. Just to give you an example, one thing we know over the past couple years is skin biopsy. Through the immunofluorescent reaction, we can detect whether the hallmark of abnormally folded, misfolded, and the phosphorate, the alpha-synuclein aggregate can be found just by this little pinch of skin biopsy. Even more advanced, there's another diagnosis tool we call the SAA, we call the seizure amplification assay, that can even help us to differentiate MSA from other alpha-synucleinopathy, including Parkinson disease and dementia with Lewy bodies. If we get a little sample from CSF, spinal cerebral fluids, even though this is probably still at the early stage, a lot of developments still ongoing, but this, this really shows you how exciting this area is now. We're really in a fast forward-moving path now. Dr Albin: It's really incredible. So, lots coming down the track in, sort of, MRI, but also with CSF diagnosis and skin biopsies. Really hoping that we can hone in some of those tools as they become more and more validated to make this diagnosis. Is that right? Dr Xie: Correct. Dr Albin: Amazing. We can talk all day about how you manage these in the clinic, and I really am going to direct our listeners to go and read your fantastic article, because you do such an elegant job talking about how this takes place in a multidisciplinary setting, if at all possible. But as a neurointensivist, I was telling you, we have so much trouble in the hospital. We have A-lines, and we have the ability to get rapid KUBs to look at Ilias, and we can have many people as lots of diagnosis, and we still have a lot of trouble treating autonomiclike symptoms. Really, really difficult. And so, I just wanted to kind of pick your brain, and I'll start with just the one of orthostatic hypotension. What are some of the tips that you have for, you know, clinicians that are dealing with this? Because I imagine that this is quite difficult to do without patients. Dr Xie: Exactly. This is indeed a very difficult symptom to deal with, particularly at an outpatient setting. But nowadays with the availability of more medication---to give an example, to treat patients with orthostatic hypertension, we have not only midodrine for the cortisol, we also have droxidopa and several others as well. And so, we have more tools at hand to treat the patient with orthostatic hypertension. But I think the key thing here, particularly for us to the patient at the outpatient setting: we need to educate the patient's family well about the natural history of the disease course. And we also need to tell them what's the indication and the potential side effect profile of any medication we prescribe to them so that they can understand what to expect and what to watch for. And in the meantime, we also need to keep really effective and timely communication channels, make sure that the treating physician and our team can be reached at any time when the patient and family need us so that we can be closely monitoring, their response, and also monitoring potential side effects as well to keep up the quality of care in that way. Dr Albin: Yeah, I imagine that that open communication plays a huge role in just making sure that patients are adapting to their symptoms, understanding that they can reach out if they have refractory symptoms, and that- I imagine this takes a lot of fine tuning over time. Dr Xie: Correct. Dr Albin: Well, this has just been such a delight to get to talk to you. I really feel like we could dive even deeper, but I know for the sake of time we have to kind of close out. Are there any final points that you wanted to share with our listeners before we end the interview? Dr Xie: I think for the patients, I want them to know that nowadays with advances in science and technology, particularly given a sample of rapid development in the diagnostic tools and the multidisciplinary and multisystemic approach to treatment, nowadays we can make an early and accurate diagnosis of the MSA, and also, we can provide better treatment. Even though so far it is still symptomatically, mainly, but in the near future we hope we can also discover disease-modifying treatment which can slow down, even pause or prevent the disease from happening. And for the treating physician and care team professionals, I just want them to know that you can make a difference and greatly help the patient and the family through your dedicated care and also through your active learning and innovative research. You can make a difference. Dr Albin: That's amazing and lots of hope for these patients. Right now, you can provide really great care to take care of them, make an early and accurate diagnosis; but on the horizon, there are really several things that are going to move the field forward, which is just so exciting. Again today, I've been really greatly honored and privileged to be able to talk to Dr Tao Xie about his article on diagnosis and management of multiple system atrophy, which appears in the August 2025 Continuum issue on movement disorders. Be sure to check out Continuum Audio episodes for this and other issues. And thank you again to our listeners for joining us today. Dr Xie: Thank you so much for having me. Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

From Florida's black bear season decision to nationwide hunting regulation changes, here's what every outdoorsman should know.   In this episode, we dive deep into today's historic Florida Fish and Wildlife Commission vote on reinstating the black bear hunting season. Mark Lance joins us to explore the science-based wildlife management strategies behind the proposal, the surge in Florida's bear population, and how public sentiment—often driven by emotion—shapes these debates. We examine historical bear management in the state, evolving bear hunting methods such as baiting and the use of dogs, and what the commission's decision could mean for conservation.   The conversation then shifts to nationwide hunting and conservation policy updates, including the reauthorization of Wisconsin's Knowles-Nelson Stewardship Fund for public lands, Wyoming's open-door approach to public legislative input, and new regulations improving hunter access across the Northeast. We highlight state-level changes such as Maryland's approval of artificial lights for deer recovery, New York's inclusion of crossbows in archery season, and New Hampshire's decision to allow air rifles for big game hunting.   We also cover the proposed Wisconsin season for sandhill cranes, the SHARKED Act's approach to shark depredation, and the importance of sportsmen staying engaged with legislative processes. Whether you hunt, fish, or simply care about wildlife management, these updates will keep you informed on the policies shaping the great outdoors.   Get the FREE Sportsmen's Voice e-publication in your inbox every Monday: www.congressionalsportsmen.org/newsletter   Sign up for FREE legislative tracking through CSF's Tracking the Capitols tool: www.congressionalsportsmen.org/tracking-the-capitols/   Follow The Sportsmen's Voice wherever you get your podcasts: https://podfollow.com/1705085498  Learn more about your ad choices. Visit megaphone.fm/adchoices

Can oil rigs actually improve marine habitats and fishing opportunities in the Gulf? The answer is an unequivocal “YES”, as this feature episode of The Sportsmen's Voice Podcast details.    Host Fred Bird is joined by CSF's Chris Horton and Kevin Bruce from Arena Energy to discuss the Rigs to Reef program—a vital conservation initiative for saltwater anglers, commercial fishermen, and outdoor enthusiasts alike. The conversation dives deep into how decommissioned oil platforms in the Gulf of America are being transformed into artificial reefs that support marine biodiversity, enhance sportfishing opportunities, and fuel local outdoor economies, along with the challenges this program faces.   They explore: Why reefing-in-place helps conserve and protect marine ecosystems and coastal fishing access, How permitting bottlenecks threaten reef development, The bipartisan push for legislation that supports this critical marine infrastructure, and Highlights from the new documentary Steel To Sanctuary, which sheds light on the reefing effort and its impact on fishermen, divers, and coastal communities.   Whether you're a saltwater angler, conservation advocate, or part of the outdoor industry, this episode breaks down how some offshore energy infrastructure can be part of a healthy future for America's marine fisheries.   Learn more about the Rigs to Reef initiative and how you can support marine conservation efforts at the intersection of policy, ecology, and the outdoor recreation economy. Watch Steel To Sanctuary - The Rigs To Reefs Story: https://rigstoreef.com    Get the FREE Sportsmen's Voice e-publication in your inbox every Monday: www.congressionalsportsmen.org/newsletter                Sign up for FREE legislative tracking through CSF's Tracking the Capitols tool: www.congressionalsportsmen.org/tracking-the-capitols/ Learn more about your ad choices. Visit megaphone.fm/adchoices

State-level conservation issues are heating up across the country as outdoor seasons approach. The Sportsmen's Voice Host Fred Bird welcomes back CSF's own Marie Neumiller to break down changing wolf management strategies in Idaho and Montana—including the use of ABC population modeling and legal challenges to trapping seasons due to grizzly bear protections. The conversation then turns to national conservation updates, including: The Senate's confirmation of Brian Nesvik, a lifelong outdoorsman, as Director of the U.S. Fish and Wildlife Service. The fight to protect surf fishing access in South Carolina, with legislative sportsmen stepping in to stop a proposed ban that would have impacted anglers and conservation funding alike. Massachusetts' debate over providing free hunting and fishing licenses to disabled veterans—well-intentioned, but with potential risks to the state's conservation funding. A look at Missouri's proposal to expand nighttime coyote hunting, offering more opportunity for predator control and sportsmen alike. Whether you're into wolf conservation, fishing access, or predator management, this episode is packed with insights for hunters, anglers, and anyone passionate about protecting America's outdoor heritage.   Get the FREE Sportsmen's Voice e-publication in your inbox every Monday: www.congressionalsportsmen.org/newsletter   Sign up for FREE legislative tracking through CSF's Tracking the Capitols tool: www.congressionalsportsmen.org/tracking-the-capitols/ Learn more about your ad choices. Visit megaphone.fm/adchoices

Parkinson disease is a neurodegenerative movement disorder that is increasing in prevalence as the population ages. The symptoms and rate of progression are clinically heterogenous, and medical management is focused on the individual needs of the patient. In this episode, Kait Nevel MD, speaks with Ashley Rawls, MD, MS, author of the article “Parkinson Disease” in the Continuum® August 2025 Movement Disorders issue. Dr. Nevel is a Continuum® Audio interviewer and a neurologist and neuro-oncologist at Indiana University School of Medicine in Indianapolis, Indiana. Dr. Rawls is an assistant professor at the University of Florida Health, Department of Neurology at the Norman Fixel Institute for Neurological Diseases in Gainesville, Florida Additional Resources Read the article:  Parkinson Disease Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @IUneurodocmom Guest: @DrRawlsMoveMD Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. Dr Nevel: Hello, this is Dr Kait Nevel. Today I'm interviewing Dr Ashley Rawls about her article on Parkinson disease, which appears in the August 2025 Continuum issue on movement disorders. Ashley, welcome to the podcast, and please introduce yourself to the audience. Dr Rawls: Thank you, Kait. Hello everyone, my name is Dr Ashley Rawls. I am a movement disorder specialist at the University of Florida Fixel Institute for Neurologic Diseases in Gainesville, Florida. It's a pleasure to be here. Dr Nevel: Awesome. To start us off talking about your article, can you share what you think is the most important takeaway for the practicing neurologist? Dr Rawls: Yes. I would say that my most important takeaway for this article is that Parkinson disease remains a clinical diagnosis. I think the field has really been advancing and trying to find a biomarker to help with diagnosis through ancillary testing. For example, with the dopamine transporter, the DAT scan, an alpha-synuclein skin biopsy, an alpha-synuclein amplification assay that can happen in blood and CSF. However, I think it's so critical to make sure that you have a very strong history and a very thorough physical exam and use those biomarkers or other testing to help with, kind of, bolstering your thoughts on what's going on with the patient. Dr Nevel: Great. And I can't wait to talk a little bit more about the ancillary testing and how you use that. Before we get to that, can you review with us some of the components of the clinical diagnosis of Parkinson disease? Dr Rawls: Yes. So, when I think about a person that comes in that might have a neurodegenerative disease, I think about two different features, mainly: both motor and Manon motor. So, for my motor features, I'm thinking about resting tremor, bradykinesia---which is fullness of movement with decrement over time---rigidity, and then a specific gait disturbance, a Parkinsonian gait, involving stooped posture, decreased arm swing. They can also have reemergent tremor while walking if they do have tremor as part of their disease process, and also in-block turning as they are walking down the hallway. So, those are my motor features that I look for. So now, when we're talking about a specific diagnosis of Parkinson disease, the one motor feature that you need to have is bradykinesia. The reason why I make sure to speak about bradykinesia, which is slowness of movement with decrement over time, is because people can still have Parkinson disease without having tremor, a resting tremor. So even though that's one of the core cardinal features that most of us will be able to notice very readily, you don't have to necessarily have a resting tremor to be diagnosed with Parkinson' disease. When I talk about nonmotor features, those are going to be the three, particularly the prodromal features that can occur even ten years before people have motor features, can be very prominent early on in the disease process. For example, hyposmia or anosmia for decrease or lack of sense of smell. Another one that we really look for is going to be RBD, or rapid eye movement behavior disorder; or REM behavior disorder, the person acting out their dreams, calling out, flailing their limbs, hitting their bed partner. And then the other one is going to be severe constipation. So those three prodromal nonmotor symptoms of hyposmia/anosmia, RBD or REM behavior disorder, and severe constipation can also make me concerned as a red flag that there is a sort of neurodegenerative issue like a Parkinson disease that may be going on with the patient. Dr Nevel: Great, thank you so much for that overview. While we're talking about the diagnosis, do you mind kind of going back to what you mentioned in the beginning and talking about the ancillary tests that sometimes are used to kind of help, again, bolster that diagnosis of Parkinson disease? You know, like the DAT or the alpha-synuclein skin biopsy. When should we be using those? Should we be getting these on everyone? And what scenarios should we really consider doing one of those tests? Dr Rawls: The scenario in which I would order one of the ancillary testing, particularly like a DAT scan or a skin biopsy, looking for alpha-synuclein is going to be when there are potential red flags or a little bit of confusion in regard to the history and physical that I need to have a little bit more clarification on. For example, if I have a patient that has a history of using dopamine blocking agents, for example, for severe depression; or they have a history of cancer diagnosis and they've been on a dopamine agent like metoclopramide; those I want to be mindful because if they're coming in to see me and they're having the symptoms of Parkinsonism---which is going to be resting tremor, bradykinesia rigidity, or gait disturbance---I need to try to figure out is it potentially due to a medication effect, particularly if they're still on the dopamine blockade medication, or is it something where they're actually having a neurodegenerative illness underneath it, like a Parkinson disease? The other situation that would make me order a DAT skin or a skin biopsy is going to be someone who is coming in that maybe has elements of essential tremor, they have more of a postural or an intention tremor that's very flapping and larger amplitude, and maybe have some mild symptoms and Parkinsonism that might be difficult to distinguish between other musculoskeletal things like arthritis, other imbalance issues from, you know, hip problems or knee problems and what have you. Then I might say, okay, let's see if there is some sort of neurodegeneration underneath this; that may be- that there could be, you know, potentially two elements like a central tremor and Parkinson disease going on. Or is this someone who actually really has Parkinson disease, but there's other factors that are kind of playing into that. Dr Nevel: Great, thank you for that. Gosh, things have really changed over the past fifteen years or so where we have this ancillary testing that we're able to use more, because what you read in the textbook isn't always what you see in clinic. And as you described, there are patients who… it's not as clear cut, and these tests can be helpful. Could you tell us more about the levodopa challenge test? How is this useful in clinical practice? And what are some key points that we should know about when utilizing this strategy for patients who we think have Parkinson disease? Dr Rawls: So, before we had all this ancillary testing with the DAT scan, the skin biopsy, the alpha-synuclein amplification assay, many times if you had a suspicion that a person that had Parkinson disease, but you weren't entirely sure, you would say, hey, listen, let us give you back the dopamine that your body may be missing and see if you have an improvement, in particular in your motor symptom. So, when I talk with my patients, I say, listen, I might have a strong suspicion that you have Parkinson disease. Doing a levodopa trial can not only be diagnostic, but also can be therapeutic as well. So, with this levodopa trial, what I end up doing is saying, okay, we're going to start the medication at a low dose because we are looking to see if you have improvement in three of the main cardinal motor symptoms. Obviously, tremor is much easier for us to see if it gets better. It's very obvious on exam, and the patients are more readily able to see it. Whereas stiffness and slowness is much harder to quantify and try to figure out. Am I stiff and slow because of potential muscle tightness from Parkinson disease, or is it something that's more of a musculoskeletal issue? So, I will tell persons, okay, we're looking for improvement in these three cardinal motor symptoms, and things that we're looking for is getting into and out of a car, into and out of a chair, turning over in bed, seeing how do we navigate ourselves in our daily lives? I give people the example of going through the grocery store, going through a busy airport. Are we able to move better and respond better to different changes in our environment which can give us a better clue of if our stiffness and slowness in particular are being improved with the medication? The other part of this is talking about potential side effects of the carbidopa- of the levodopa in particular. One big thing that I think limits people initially is going to be the nausea, vomiting, potential GI upset when starting this medication initially. So, oftentimes I will find people coming in, oh, you know, my outside doctor started me immediately on one tab of carbidopa/levodopa three times per day. I got nauseous, I threw up, and I never took the medication again. So often times I will start low and go slow because once someone throws up my medication, they are not going to want to take it again---with good reason. So, often times I will ask the patient, hey listen, are you very sensitive to medications? If you are very sensitive, we might start one tablet per day for a week, one tablet twice a day, and then go up until we get to two tablets three times a day if we're talking about carbidopa/levodopa. If someone is not as sensitive then I might go up a little bit quicker. What do we mean when we talk about 600 milligrams per day? So usually, the amount that I use is carbidopa/levodopa, 25/100; so, 100 milligrams being the levodopa portion. Many people just start off at 1 tab 3 times a day, which gives you 300 milligrams of levodopa, and they say, oh, it didn't work, I must not have Parkinson or something else. Well, it just may have been that we did not give an adequate trial and adequate dose to the person. Now if they're not able to tolerate the medication because of the side effects, that's something different. But if they don't have side effects and don't notice a difference, there is room to increase the carbidopa/levodopa or the levodopa replacement that you are using so that you can give it, you know, a very good try to see, is it actually improving resting tremor, bradykinesia and rigidity? Dr Nevel: Yeah, great. Thanks for that. When you diagnose a patient with Parkinson disease, how do you counsel that patient? How do you break that difficult news? And how do you counsel them on what to expect in the future and goals of treatment? I know that's a lot in that question, but it also is a lot that you do in one visit, oftentimes, or at least introduce these kind of concepts to patients in a single visit. Dr Rawls: One thing that I think is helpful for me is trying to understand where the patients and their families are when they come in. Because some of the patients come in and have no prior inkling that they may have a neurodegenerative illness like Parkinson disease. Some of my patients come in and say, I'm here for a second opinion for Parkinson disease. So, then I have an idea of where we are in regard to potential understanding of how to start the conversation going forward. If it is someone who is coming in and has not heard about Parkinson disease, or their family has not been made aware that that's the one reason why they're coming to see a movement disorder specialist, then I will start at the beginning After we finish our history, do a very thorough physical exam, I will talk about things that I heard in the history and that I see on the physical exam that make me concerned for a disease like Parkinson disease. I make sure to tell them where I'm getting my criteria from and not just start off, I think you have Parkinson, here's your medication. I think that's very jarring when you're talking with patients and their families, particularly if they had no idea that this could be a potential diagnosis on the table. Like I said, I will start off with recounting, this is what I've heard in your history that makes me concerned. This is what I've seen on your physical exam that makes me concerned. And I think you have Parkinson disease and here is why. And I'll tell them about the tenants like we discussed about Parkinson disease, both the motor and nonmotor symptoms that we see. So that's kind of the first part is, I make sure to lay it out and then open the room up for some questions and clarification. The other portion of this is that, when I'm talking about counseling the patient, I say, we do not expect Parkinson disease to decrease your lifespan. However, over time, our persons, because it is a neurodegenerative illnesses will accumulate deficits over time. So, more stiffness, more slowness, more walking problems. They may, if they have tremor, the tremor may become worse. If they don't have tremor, they might develop tremor in the future. If we're talking about the nonmotor symptoms that we talk about, the main ones are going to be issues with urinary problems, issues with bowels, and then the other thing is going to be neuropsychiatric issues like anxiety and depression. And those things become more prominent, usually, the nonmotor symptoms later on in the disease process, and then also cognitive impairment as well. I really want to make sure that they have the information that I'm seeing, and if there's anything that they want to correct on their end, as in they're saying, oh wait, well, actually I noticed something else, then that's usually when that comes out around kind of the wrapping-up portion of the visit. So, I think that's really important to, one, be very clear in what I am seeing and if there's red flags, and then tell them, okay this is not going to shorten your lifespan. However, over time, we do have other issues and problems that will arise and we can support you as best as we can through that. The one thing I also been very open with people about is- because our patients will say, is there anything I can do? What can be done? Is there any medication to slow down or stop things? And I let people know that unfortunately, right now there's not an intervention that slows down, stops, or reverses disease progression, with the exception of exercise. Consistent exercise has been found to help to slow down disease progression, okay? And also, it can help to release the dopamine already being made innately in the brain. And also, it can help with our cardiovascular health in the big thing: being balanced. Core strength, quadricep strength. So that's also something that people can work on that they should. And I let people know that exercise is as important as the medications themselves. Dr Nevel: Absolutely. And it's incredible how much they incorporate exercise into their daily lives and get active, people who weren't active before their diagnosis, and how much that can help. One question that I think patients sometimes ask is, when they understand how carbidopa/levodopa works and what the expectations are for that medication, that it's not a disease-modifying medication, but that it can help with their symptoms. And then they kind of hear, well as time goes on, they need higher doses or, you know, it doesn't control their motor symptoms as well. They'll say, okay well, is it better to wait then? Should I wait to start carbidopa/levodopa? Like in my mind, I'm only maybe going to get X amount of time from carbidopa/levodopa. So, I'd rather wait to start it than start it now. What do you say to them and how do you counsel them through that? Dr Rawls: So that is a common question that I do get with my patients. So, I tell people, I'm here for you. And it really depends on how you feel at this time. Because you have to weigh the risks and benefits of the medication itself. If someone who's very, very mild decides to take the medication, they feel nauseous, they're just going to say, hey, listen, it's not for me right now. I don't feel like I need it, and then stop, which is with definitely within their right. But what I always counsel patients as well is to say, the dopamine-producing neurons in the substantia nigra are starting to die over time. That is why we are getting the signs and symptoms of Parkinson disease. At some point, your brain is not going to produce enough dopamine that is needed for you to move when you want to move and not move when you don't want to move. Okay? Giving you at least the motor symptoms of Parkinson disease. With this, it's not that the medication stops working, it's just that you need more dopamine to help replace the dopamine that's being lost. However, the dopamine that you are taking or levodopa that you're taking orally is not going to be released as consistently as it is in your brain on demand and shut off when you don't need it. Hence the reason we get more motor fluctuations. Also, potential side effects in the medication like orthostatic hypertension, hallucinations, impulse control disorders. Because you're having to take more escalating doses, those side effects can become more prominent and also lead us to have to balance between the side effects and the medication itself. So, it's not that the medication does not work, your body needs more of it. Some people will say, oh, well, I want to wait, and I say, that's completely fine. However, my cutoff is basically saying, if you are finding that you, as the person who's afflicted is not able to get up in the morning like you want to, you're avoiding going to walk your dog or working in your garden, you know, because you feel stiff and feel slow; you're avoiding, you know, going out to the community, having lunch with your friends or your family because you're embarrassed by your tremor; this is something that is keeping you from living your life. And that's the time that we need to strongly consider starting the medications. So, a person afflicted will accumulate deficits. However, it's how much the deficits are going to affect you. So, if it's really affecting your life, we have tools and ways to help mitigate that. Dr Nevel: Yeah, absolutely. Are there any aspects of Parkinson disease management that you feel are maybe underrecognized or perhaps underutilized? In other words, you know, are there things that we the listeners should be maybe more aware of or think about offering or recommending to our patients that you think maybe aren't as much as they could be? Dr Rawls: I will say the nonmotor symptoms---in particular the neuropsychiatric symptoms with the anxiety and depression, usually later on disease process but also can be earlier as well---I think that is going to be something that is recognized but maybe undertreated in a lot of our patient population. I think part of that is also the fluctuations in dopamine that are occurring naturally in the person, but also, our patients, oftentimes with their medication regimen, really have to be on the ball taking the medication. If they're even 15 minutes late, 10 minutes late, 5 minutes late, we're now off, and now we're waiting for it to kick in. And so that can cause a lot of anxiousness even throughout the day. And then knowing that slowly over time that they're going to accumulate these motor and nonmotor deficits can definitely be problematic as well. There is obvious reason for this underlying potential anxiety and depression. And while we do talk about that and bring that up, sometimes patients will say, oh well, I don't think it's a problem right now. I don't have to mess with this. But usually at some point it does become an issue that usually the family members will bring up and saying, hey, you know, my loved one is very anxious. Or I've noticed that they're just really disengaged from what's going on in their lives and they are not talking as much, they're not going out as much. Again, that could be a combination of depression/anxiety, but it also can be a physical- a combination of, I'm not physically able to do these things, or, they're much more difficult for me to initiate doing these activities. I always want to be mindful. If my patients come in and they already have a diagnosis of depression or anxiety and they're already being treated by a mental health counselor, provider, or a psychiatrist, then I will work with providers so that we can try to optimize their medication regimen. The other thing is, well, if this is the first time that they're really being seen by someone and talking about their anxiety and depression, then oftentimes I will have them go back to their primary care and see if maybe an SSRI or SNRI will be helpful to try to help with the neuropsychiatric symptoms they may be experiencing. So that's one big one. Another one that I think that might be a little bit underappreciated is going to be drooling. Sometimes I'll come in and see my patients and notice some drooling that's happening with the mouth being open, not being able to initiate the swallowing reflex consistently throughout the day. Or they may be patting their face a lot with a napkin or a towel and then bringing that up and bringing it to light. Oh yeah. I have a lot of drooling while I'm awake. It's on my shirt. It's embarrassing. I feel like it's a little bit too much for me or my family. We have to put a bib on because I'm just drooling all throughout the day. That can really be uncomfortable and cause skin breakdown. It can also be socially embarrassing. So, there are some tools that I talk to people about with drooling. One thing I start with is going to be using sugar-free gum or candy while the person is awake to help initiate the swallow reflex, and sometimes that's all that's needed. There are other agents that can be used---like glycopyrrolate, sublingual atropine drops, and scopolamine patches---that can help with decreasing saliva production. But there can be side effects of making the entire body feel dry, and then also potential cardiac arrhythmias. If those are not helpful or they're contraindicated with the patient, another thing is going to be botulinum toxin injections. So those can be done on the parotid and salivary glands to decrease the amount of saliva that's being produced. So oftentimes people will come to me, because I'm also a botulinum toxin injector. I've been sent by some of my colleagues to inject our persons that have significant sialorrhea. Dr Nevel: Wonderful. Well, thank you so much for chatting with me today about your article. Again, today I've been interviewing Dr Ashley Rawls about her article on Parkinson disease, which appears in the August 2025 Continuum issue on movement disorders. Be sure to check out Continuum Audio episodes from this and other issues. And thank you to our listeners for joining today. And thank you, Ashley, for sharing all your knowledge with us today. Dr Rawls: Thank you, Kate, I appreciate your time. And have a great day, everyone. Dr Monteith: This is Dr Teshmae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

New laws and regulations are reshaping the future of hunting, fishing, and outdoor access nationwide.   In this episode of The Sportsmen's Voice Roundup, we break down major legislative updates affecting hunters, anglers, and conservation advocates. Topics include Pennsylvania's new Sunday hunting implementation for the 2025–2026 season, Nebraska's decision to raise mountain lion harvest limits, and the introduction of the SHARKED Act to protect anglers from unwanted shark encounters. We also cover Wyoming's stance on landowner hunting tags, progress on knife rights in Delaware, and takeaways from the Southern Legislative Forum.   Whether you hunt whitetail in the East or chase elk out West, staying informed on these legislative moves is key to protecting your access, rights, and role in conservation.   Key Highlights: Sunday Hunting in Pennsylvania: Newly approved for the 2025–2026 hunting season. Mountain Lion Hunting in Nebraska: Expanded harvests reflect strong predator populations. The SHARKED Act: A bipartisan effort to reduce shark depredation by establishing a task force to work with fisheries management. Wyoming Landowner Tags: State commission rejects proposed changes, maintaining the current landowner tag allocation system. Delaware Knife Rights: Updates aim to modernize outdated carry laws for hunters and outdoorsmen sent to Governor. Southern Legislative Forum Recap: Key insights from pro-sportsmen lawmakers across the South.   Get the FREE Sportsmen's Voice e-publication in your inbox every Monday: www.congressionalsportsmen.org/newsletter   Sign up for FREE legislative tracking through CSF's Tracking the Capitols tool: www.congressionalsportsmen.org/tracking-the-capitols/ Learn more about your ad choices. Visit megaphone.fm/adchoices

A 47 year old male presents with intermittent, unilateral nasal drainage and headache. What do you do? In this episode of the BackTable Podcast, Dr. Satyan Sreenath, a rhinologist at Indiana University, and Dr. Sanjeet Rangarajan, a rhinologist at Case Reserve University, examine complex cases involving CSF leaks and encephaloceles. --- SYNPOSIS The doctors discuss diagnostic approaches, imaging techniques, and innovative surgical methods, using endoscopic and minimally invasive strategies. The conversation highlights the difficulties of diagnosing and surgically repairing these leaks, focusing on their personal experiences and preferred techniques. Through detailed case studies with imaging and surgical videos, they explore the importance of meticulous planning, interdisciplinary collaboration, and adaptive strategies to manage these challenging conditions effectively. A must watch on Youtube! --- TIMESTAMPS 00:00 - Introduction02:17 - Patient Case 1: “Headache and Drippy Nose..”02:58 - Diagnostic Imaging and Findings07:55 - Surgical Approach and Postoperative Care16:52 - Patient Case 2: “Drippy nose and nasal congestion… just allergies right?”17:32 - Diagnostic Imaging and Findings20:21 - Surgical Approach and Postoperative Care29:03 - Patient Case 3: “Runny nose after my MVC 3 years ago…”29:21 - Imaging and Surgical Approach Discussion31:46 - Post-Operative Challenges and Patient Follow-Up42:46 - Patient Case 4: “Continuous nasal drainage BOTH sides”43:31 - Imaging and Findings 44:43 - Surgical Approach for Bilateral Defects56:39 - Final Thoughts --- RESOURCES Dr. Satyan Sreenath profile:https://iuhealth.org/find-providers/provider/satyan-b-sreenath-md-1821999 Dr. Sanjeet Rangarajan's profile:https://www.uhhospitals.org/doctors/Rangarajan-Sanjeet-164956839

With the increase in the public's attention to all aspects of brain health, neurologists need to understand their role in raising awareness, advocating for preventive strategies, and promoting brain health for all. To achieve brain health equity, neurologists must integrate culturally sensitive care approaches, develop adapted assessment tools, improve professional and public educational materials, and continually innovate interventions to meet the diverse needs of our communities. In this BONUS episode, Casey Albin, MD, speaks with Daniel José Correa, MD, MSc, FAAN and Rana R. Said, MD, FAAN, coauthors of the article “Bridging the Gap Between Brain Health Guidelines and Real-world Implementation” in the Continuum® June 2025 Disorders of CSF Dynamics issue. Dr. Albin is a Continuum® Audio interviewer, associate editor of media engagement, and an assistant professor of neurology and neurosurgery at Emory University School of Medicine in Atlanta, Georgia. Dr. Correa is the associate dean for community engagement and outreach and an associate professor of neurology at the Albert Einstein College of Medicine Division of Clinical Neurophysiology in the Saul Korey Department of Neurology at the Montefiore Medical Center, New York, New York. Dr. Said is a professor of pediatrics and neurology, the director of education, and an associate clinical chief in the division of pediatric neurology at the University of Texas Southwest Medical Center in Dallas, Texas. Additional Resources Read the article: Bridging the Gap Between Brain Health Guidelines and Real-world Implementation Subscribe to Continuum®: shop.lww.com/Continuum Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @caseyalbin Guests: @NeuroDrCorrea, @RanaSaidMD Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum. This exclusive Continuum Audio interview is available only to you, our subscribers. We hope you enjoy it. Thank you for listening. Dr Albin: Hi all, this is Dr Casey Albin. Today I'm interviewing Dr Daniel Correa and Dr Rana Said about their article on bridging the gap between brain health guidelines and real-world implementation, which they wrote with Dr Justin Jordan. This article appears in the June 2025 Continuum issue on disorders of CSF dynamics. Thank you both so much for joining us. I'd love to just start by having you guys introduce yourselves to our listeners. Rana, do you mind going first? Dr Said: Yeah, sure. Thanks, Casey. So, my name is Rana Said. I'm a professor of pediatrics and neurology at the University of Texas Southwestern Medical Center in Dallas. Most of my practice is pediatric epilepsy. I'm also the associate clinical chief and the director of education for our division. And in my newer role, I am the vice chair of the Brain Health Committee for the American Academy of Neurology. Dr Albin: Absolutely. So just the right person to talk about this. And Daniel, some of our listeners may know you already from the Brain and Life podcast, but please introduce yourself again. Dr Correa: Thank you so much, Casey for including us and then highlighting this article. So yes, as you said, I'm the editor and the cohost for the Brain and Life podcast. I do also work with Rana and all the great members of the Brain Health Initiative and committee within the AAN, but in my day-to-day at my institution, I'm an associate professor of neurology at the Albert Einstein College of Medicine in the Montefiore Health System. I do a mix of general neurology and epilepsy and with a portion of my time, I also work as an associate Dean at the Albert Einstein College of Medicine, supporting students and trainees with community engagement and outreach activities. Dr Albin: Excellent. Thank you guys both so much for taking the time to be here. You know, brain health has really become this core mission of the AAN. Many listeners probably know that it's actually even part of the AAN's mission statement, which is to enhance member career fulfillment and promote brain health for all. And I think a lot of us have this kind of, like, vague idea about what brain health is, but I'd love to just start by having a shared mental model. So, Rana, can you tell us what do you mean when you talk about brain health? Dr Said: Yeah, thanks for asking that question. And, you know, even as a group, we really took quite a while to solidify, like, what does that even mean? Really, the concept is that we're shifting from a disease-focused model, which we see whatever disorder comes in our doors, to a preventative approach, recognizing that there's a tremendous interconnectedness between our physical health, our mental health, cognitive and social health, you know, maintaining our optimal brain function. And another very important part of this is that it's across the entire lifespan. So hopefully that sort of solidifies how we are thinking about brain health. Dr Albin: Right. Daniel, anything else to add to that? Dr Correa: One thing I've really liked about this, you know, the evolution of the 2023 definition from the AAN is its highlight on it being a continuous state. We're not only just talking about prevention of injury and a neurologic condition, but then really optimizing our own health and our ability to engage in our communities afterwards, and that there's always an opportunity for improvement of our brain health. Dr Albin: I love that. And I really felt like in this article, you walked us through some tangible pillars that support the development and maintenance of this lifelong process of maintaining and developing brain health. And so, Daniel, I was wondering, you know, we could take probably the entire time just to talk about the five pillars that support brain health. But can you give us a pretty brief overview of what those are that you outlined in this article? Dr Correa: I mean, this was one of the biggest challenges and really bundling all the possibilities and the evidence that's out there and just getting a sense of practical movement forward. So, there are many organizations and groups out there that have formed pillars, whether we're calling them seven or eight, you know, the exact number can vary, but just to have something to stand on and move forward. We've bundled one of them as physical and sleep health. So really encouraging towards levels of activity and not taking it as, oh, that there's a set- you know, there are recommendations out there for amount of activity, but really looking at, can we challenge people to just start growing and moving forward at their current ability? Can we challenge people to look at their sleep health, see if there's an aspect to improve, and then reassess with time? We particularly highlight the importance of mental health, whether it's before a neurologic condition or a brain injury occurs or addressing the mental health comorbidities that may come along with neurologic conditions. Then there's of course the thing that everyone thinks about, I think, with brain health in terms of is cognitive health. And you know, I think that's the first place that really enters either our own minds or as we are observers of our elder individuals in our family. And more and more there has been the highlight on the need for social interconnectedness, community purpose. And this is what we include as a pillar of social health. And then across all types of neurologic potential injuries is really focusing on the area of brain injury. And so, I think the area that we've often been focused as neurologists, but also thinking of both the prevention along with the management of the condition or the injury after it occurs. Dr Albin: Rana, anything else to add to that? That's a fantastic overview. Dr Said: Daniel, thank you for- I mean, you just set it up so beautifully. I think the other thing that maybe would be important for people to understand is that as we're talking through a lot of these, these are individual. These sound like very individual-basis factors. But as part of the full conversation, we also have to understand that there are some factors that are not based on the individual, and then that leads to some of the other initiatives that we'll be talking about at the community and policy levels. So, for example, if an individual is living in an area with high air pollution. Yes, we want them to be healthy and exercise and sleep, but how do we modify those factors? What about lead leaching from our aging pipes or even infectious diseases? So, I think that outside of our pillars, this is sort of the next step is to understand what is also at large in our communities. Dr Albin: That's a really awesome point. I love that the article really does shine through and that there are these individual factors, and then there there's social factors, there's policy factors. I want to start just with that individual because I think so many of our patients probably know, like, stress management, exercise, sleep, all of that stuff is really important. But when I was reading your article, what was not so obvious to me was, what's the role that we as neurologists should play in advocating? And really more importantly, like, how should we do that? And again, it struck me that there are these kind of two issues at play. And one is that what Daniel was saying that, you know, a lot of our patients are coming because they have a problem, right? We are used to operating in this disease-based care, and there's just limited time, competing clinical demands. If they're not coming to talk about prevention, how do we bring that in? And so Rana, maybe I'll start with you just for that question, you know, for the patients who are seeing us with a disease complaint or they're coming for the management of a problem, how are you organizing this at the bedside to kind of factor in a little bit about that preventative brain health? Dr Said: You know, I think the most important thing at the bedside is, one, really identifying the modifiable risk factors. These have been well studied, we understand them. Hypertension, diabetes, smoking, weight management. And we know that these definitely are correlative. So is it our role just to talk about stroke, or should we talk about, how are you managing your blood pressure? Health education, if there was one major cornerstone, is elevating health literacy for everyone and understanding that patients value clear and concise information about brain health, about modifiable risk factors. And the corollary to that, of course, are what are the resources and services? I completely understand---I'm a practicing clinician---the constraints that we have at the bedside, be it in the hospital or in our clinics. And so being the source of information, how are we referring our families and individuals to social workers, community health worker support, and really partnering with them, food banks, injury prevention programs, patient advocacy organizations? I think those are really ways that we can meet the impacts that we're looking at the bedside that can feel very tangible and practical. Dr Albin: That's really excellent advice. And so, I'd like to ask a follow-up question. With your knowledge of this, trying to get more multidisciplinary buy-in from your clinic so that you really have the support to get these services that are so critically important. And how do you do that? Dr Said: Yeah, I think it's, one, being a champion. So, what does a champion mean? It means that somebody has to decide this is really important. And I think we all realize that we're not the only ones in the room who care about this. We're all in this, and we all care about it. But how do we champion it and carry it through? And so that's the first. Second you find your partnerships: your social workers, your case managers, your other colleagues. And then what is the first-level entry thing that you can do? So for example, I'm a pediatric epileptologist. One of the things we know is that in pediatric epilepsy, depression and anxiety are very strong comorbidities. So, before we get to the point where a child is in distress, every single one of our epilepsy patients who walks in the door over the age of twelve has an age-appropriate screener that is given to them in both English and Spanish. And we assess it and we determine stratifying risk. And then we have our social workers on the back end and we decide, is this a child who needs resources? Is this a child who needs to be walked to the emergency room, escorted? And anything in between. And I think that that was a just a very tangible example of, every single person can do this and ask about it. And through the development of dot phrases and clear protocols, it works really well. Dr Albin: I love that, the way that you're just being mindful. At every step of the way, we can help people towards this lifelong brain health. And Daniel, you work with an adult population. So I wonder, what are your tips for bringing this to a different patient population? Dr Correa: Well, I think---adult or child---one thing that we often are aware of with so many of the other things that we're doing in bedside or clinic room counseling, but we don't necessarily think of in this context of brain health, is, remember all the people in the room. So, at the bedside, whether it's in the ICU, discharge counseling, the initial admission, the whole family is often involved and really concerned about the active issue. But you can look for opportunities- we often try to counsel and support families about the importance of their own sleep and rest and highlighting it not just as being there for their family member, but highlighting it to them as a measure of their own improvement of their brain health. So, looking at ways where, one, I try to find, is there something I can do to support and educate the whole family about their brain health? And then- and with an epilepsy, or in many other situations, I try to look for one comorbidity that might be a pillar of brain health to address that maybe I wasn't already thinking. And then I consider, is there an additional thing that they wouldn't naturally connect to their epilepsy or their headaches that I can bring in for them to work on? You know, we can't often give people twelve different things to work on, and they'd just feel like, okay like, you have no realistic understanding of my life. But if we can just highlight on one, and remind them that there can be many more ways to improve their health and to follow up either with us as their neurologist or their future primary care doctors to address those additional needs. Again, I would really highlight the importance of a multidisciplinary approach and looking for opportunities. We've too often, I feel, relied on primary care as being the first line for addressing unmet social health needs. We know that so many people, once they have a neurologic condition or the potential, even, of a neurologic condition, they're concerned about dementia or something, they may view us, as their neurologist, as their most important provider. And if they don't have the resource of time and money to show up at other doctors, we may be the first one they're coming to. And so, tapping into your institution's resources and finding out, are there things that are available to the primary care services that for some reason we're not able to get on the inpatient side or the outpatient side? Referring to social workers and care workers and showing that our patients have an independent need, that they're not somehow getting captured by the primary care doctors. Dr Albin: I really love that. I think that we- just being more invested and just being ready to step into that role is really important. I was noticing in this article, you really call that being a brain health ambassador, being really mindful, and I will direct all of our listeners to Figure 3, which really captures what practitioners can do both at the bedside, within their local community, and even at the professional society level, to really advocate for policies that promote brain wellness. Rana, at the very beginning of this conversation, you noted, you know, this is not just an individual problem. This really is something that is a component of our policy and the structure of our local communities. I really loved in the article, there's a humility that this cannot be just a person-by-person bedside approach, that this is a little bit determined by the social determinants of health. And so, Rana, can you walk us through a little bit of what are the social determinants of health, and why are these so crucially important when we think about brain health for all? Dr Said: Yeah, social determinants of health are a really key factor that it looks at, what are the health factors that are environmental; for example, that are not directly like what your blood pressure is, what, you know, what your BMI is, that definitely impact our health outcomes. So, these include environmental things like where people are born, where they live, where they learn, work, play, worship, and age. It encompasses factors like your socioeconomic status, your education, the neighborhoods where you are living, definitely healthcare access. And then all of this is in a social and community context. We know that the impact of social determinants of health on brain health are profound for the entire lifespan and that- so, for example, if someone is from a disadvantaged background or that leads to chronic stress, they can have limited access to healthcare. They can have greater risk of exposure to, let's say, environmental toxins, and all of that will shape how their brain health is. Violence, for example. And so, as we think about how we're going to target and enhance brain health, we really have to understand that these are vulnerable populations, special high-risk populations, that often have a disproportionate burden of neurologic disorders. And by identifying them and then developing targeted interventions, it promotes health equity. And it really has to be done in looking at culturally- ethnocultural-sensitive healthcare education resources, thinking about culturally sensitive or adaptive assessment tools that work for different populations so that these guidelines that we have, that we've already identified as being so valuable, can be equitably applied, which is one crucial component of reducing brain health risk factors. And lastly, at the neighborhood level, this is where we really rely on our partnerships with community partners who really understand their constituents and they understand how to have the special conversations, how to enhance brain health through resource utilization. And so, this is another plug for policy and resources. Dr Albin: I love that. And thinking about the neighborhood and the policy levels and all the things that we have to do. Daniel, I'd like to ask you, is there anything else you would add? Dr Correa: Yeah, you know, so I really wanted to come back to this thing is that often and unfortunately, in the beginning understanding of social determinants of health, they're thought of as a positive or a negative factor, and often really negative. These are just facts. They're aspects about our community, our society, and some of them may be at the individual level. They're not at fault of any individual or community, or even our society. They're just the realities. And when someone has a factor that may predict a health disparity or an unmet social need---I wanted to come back to that concept and that term---one or two positive factors that are social determinants of health for that individual are unmet social needs. It's a point of promise. It's a potential to be addressed. And seeking ways to connect them with community services, social work, caregivers, these are ways where- that we can remove a barrier to, so that the possibility of the recommendations that we're used to doing, giving recommendations about medications and management, can be fully appreciated for that person. And the other aspect is, like brain health, this is a continuous state. The social determinants of health may be different for the child, the parent, and the elderly family member in the household, and there might be some that are shared across them. And when one of those individuals has a new medical illness or a new condition, a stroke, and now has a mobility limitation, that may change a social determinant of health for that person or for anyone else in the family, the other people now becoming caregivers. We're used to this. And for someone after a stroke or traumatic brain injury, now they have mobility changes. And so, we work on addressing those. But thinking on how those things now become a barrier for engaging with community and accessing things, something as simple as their pharmacy. Dr Albin: I hear a lot of “this is a fluid situation,” but there's hope here because these are places that we can intervene and that we can really champion brain health throughout this fluid situation. Which kind of brings me to what we're going to close out with, which is, I'm going to have you do a little thought exercise, which is that you find a magic lamp and a genie comes out. And we'll call this the brain health genie. The genie says that they are going to grant you one wish for the betterment of brain health. Daniel, I'll start with you. What is the one thing that you think could really move the needle on promoting and maintaining brain health? Dr Correa: I will jump on nutrition and food access. If we could somehow get rid of food insecurity and have access to whole and fresh foods for everyone, and people could go back to looking at opportunities from their ancestral and cultural experiences to cook and make whole-food recipes from their own cultures. Using something like the Mediterranean diet and the mind diet as a framework, but not looking at those as cultural barriers that we somehow all have to eat a certain way. So, I think that would really be the place I would go to first that would improve all of our brain health. Dr Albin: I love that. So, wholesome eating. Rana, how about you? One magic wish. Dr Said: I think traumatic brain injury prevention. I think it's so- it feels so within our reach, and it just always is so heart-hurting when you think that wearing helmets, using seatbelts, practicing safety in sports, gun safety---because we know unfortunately that in pediatric patients, firearm injury is the leading cause of traumatic brain injury. In our older patients, fall reduction. If we could figure out how to really disseminate the need for preventative measures, get everyone really on board, I think this is- the genie wouldn't have to work too hard to make that one come true. Dr Albin: I love that. As a neurointensivist, I definitely feel that TBI prevention. We could talk about this all day long. I really wish we had a longer bit of time, but I really would direct all of our listeners to this fantastic article where you give really practical advice. And so again, today I've been interviewing Drs Daniel Correa and Rana Said about their article on bridging the gap between brain health guidelines and real-world implementation, written with Dr Justin Jordan. This article appears in the most recent issue of Continuum on the disorders of CSF dynamics. Be sure to check out Continuum Audio episodes from this and other issues. And thank you so much for our listeners for joining us today. Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. We hope you've enjoyed this subscriber-exclusive interview. Thank you for listening.

Discover how hunters, educators, and advocates are reshaping the future of hunting and conservation. In this episode of The Sportsmen's Voice, host Fred Bird explores the R3 movement—Recruitment, Retention, and Reactivation—and its critical role in the future of hunting, shooting sports, and wildlife conservation across the U.S. Fred first welcomes Taniya Bethke, a national voice for inclusive hunting access, to talk about the importance of community engagement, education, and partnerships in growing support for hunting and public lands. She breaks down how to better connect with urban populations and why shifting public perception is essential to long-term success in conservation. Then, Courtney Braunns of the Pennsylvania Game Commission joins to share what's working—and what's not—at the state level. She highlights youth hunting initiatives, college outreach, and the impact of Sunday hunting legalization in reversing declining participation trends. She also discusses the challenges of land access and the importance of mentorship programs for first-time hunters. Finally, Fred sits down with Greg Kretschmar, longtime radio host and outdoor advocate in New England. They dive into the role of media in shaping opinions on hunting, how social platforms can both help and hurt, and why personal outdoor experiences remain powerful tools for changing minds and hearts. Greg reflects on the therapeutic value of time in nature and the responsibility of hunters to lead by example. Takeaways R3 Framework: Recruitment, retention, and reactivation efforts are vital to hunting's future. Urban Outreach: Engaging city dwellers and college students expands the hunting base. Land Access: A top barrier to new hunter participation, especially in metro areas. Mentorship Matters: New hunters thrive when guided by experienced outdoorsmen and women. Conservation Funding: Hunters contribute directly through licenses and excise taxes. Social Media's Impact: Perception of hunting is shaped—often negatively—online. Therapeutic Outdoors: Hunting and time in nature support mental health and well-being. Inclusive Messaging: Public lands belong to everyone—education must reflect that. Wildlife Management: Hunting plays a vital role in population control and habitat care. Partnerships Matter: Collaborations between agencies, NGOs, and hunters amplify success.   Get the FREE Sportsmen's Voice e-publication in your inbox every Monday: www.congressionalsportsmen.org/newsletter                Sign up for FREE legislative tracking through CSF's Tracking the Capitols tool: www.congressionalsportsmen.org/tracking-the-capitols/ Learn more about your ad choices. Visit megaphone.fm/adchoices

Ballot box biology, poaching crackdowns, and new hunting tech—here's what's shaping conservation policy. In this episode of The Sportsmen's Voice Roundup, Fred dives into the most important hunting and conservation news across the country. From stronger poaching penalties in New Hampshire to landmark private property rights legislation in North Carolina, sportsmen and women face major changes that will impact how we hunt, fish, and manage wildlife. Fred breaks down how ballot box biology continues to threaten science-based wildlife management and what hunters can do to fight back. You'll also hear how new hunting technologies are being debated for use in Indiana, and why smart tech could actually improve safety and reliability in the field. This episode is packed with updates on conservation funding, sportsmen's caucus collaboration, and how public education is key to defending our outdoor traditions. Whether you're a hunter, angler, or other conservationist, you'll come away informed and fired up to protect what matters most. Key Highlights: New Hampshire considers increased penalties for wildlife poaching. North Carolina advances property rights for private landowners. CSF defeats anti-sportsman legislation and passes key pro-hunting bills. Ballot initiatives continue to sideline science in wildlife management decisions. Indiana weighs the pros and cons of new hunting technologies. Conservation funding remains vital for effective fish and game management. National unity among hunters and anglers is critical to shaping future policy.   Get the FREE Sportsmen's Voice e-publication in your inbox every Monday: www.congressionalsportsmen.org/newsletter   Sign up for FREE legislative tracking through CSF's Tracking the Capitols tool: www.congressionalsportsmen.org/tracking-the-capitols/ Learn more about your ad choices. Visit megaphone.fm/adchoices

Childhood-onset hydrocephalus encompasses a wide range of disorders with varying clinical implications. There are numerous causes of symptomatic hydrocephalus in neonates, infants, and children, and each predicts the typical clinical course across the lifespan. Etiology and age of onset impact the lifelong management of individuals living with childhood-onset hydrocephalus. In this episode, Casey Albin, MD, speaks with Shenandoah Robinson, MD, FAANS, FAAP, FACS, author of the article “Childhood-onset Hydrocephalus” in the Continuum® June 2025 Disorders of CSF Dynamics issue. Dr. Albin is a Continuum® Audio interviewer, associate editor of media engagement, and an assistant professor of neurology and neurosurgery at Emory University School of Medicine in Atlanta, Georgia. Dr. Robinson is a professor of neurosurgery, neurology, and pediatrics at Johns Hopkins University School of Medicine in Baltimore, Maryland. Additional Resources Read the article: Childhood-onset Hydrocephalus Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @caseyalbin Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. Dr Albin: Hi, this is Dr Casey Albin. Today I'm interviewing Dr Shenandoah Robinson about her article on childhood onset hydrocephalus, which appears in the June 2025 Continuum issue on disorders of CSF dynamics. Dr Robinson, thank you so much for being here. Welcome to the podcast. I'd love to start by just having you briefly introduce yourself to our audience. Dr Robinson: I'm a pediatric neurosurgeon at Johns Hopkins, and I'm very fortunate to care for kids and children from the neonatal intensive care unit all the way up through young adulthood. And I have a strong interest in developing better treatments for hydrocephalus. Dr Albin: Absolutely. And this was a great article because I really do think that understanding how children with hydrocephalus are treated really does inform how we can care for them throughout the continuum of their lifespan. You know, I was shocked in reading your article about the scope of the problem for childhood onset hydrocephalus. Can you walk our listeners through what are the most common reasons why CSF diversion is needed in the pediatric population? Dr Robinson: For the United States, and Canada too, the most common reasons are spina bifida---so, a baby that's born with a myelomeningocele and then develops associated hydrocephalus---and then about equally as common is posthemorrhagic hydrocephalus of prematurity, congenital causes such as from aquaductal stenosis, and other genetic causes are less common. And then we also have kids that develop hydrocephalus after trauma or meningitis or tumors or other sort of acquired problems during childhood. Dr Albin: So, it's a really diverse and sort of heterogeneous causes that across sort of the, you know, the neonatal period all the way to, you know, young adulthood. And I'm sure that those etiologies really shift based on sort of the subgroup population that you're talking about. Dr Robinson: Yes, they definitely shift over time. Fortunately for our kids that are born with problems that raise concerns, such as myelomeningocele or if they're born preterm, they sort of declare themselves by the time they're a year old. So, if you're an adult provider, they should have defined themselves and it's unlikely that they will suddenly develop hydrocephalus as a teenager or older adult. Dr Albin: Totally makes sense. I think many of the listeners to this podcast are adult neurologists who are probably very familiar with external ventriculostomies for temporary CSF diversion, and with the more permanent ventricular peritoneal shines or ventricular atrial or plural shines that are needed when there's the need for permanent diversion. But you described in your article two procedures that provide temporary CSF diversion that I think many of our listeners are probably not as familiar with, which is the ventricular access devices and ventriculosubgaleal shunts. Can you briefly describe what those procedures provide? Who are the candidates for them? And then what complications neurologists may need to think about if they're consulted for comanagement in one of these complex patients? Dr Robinson: Well, the good thing is that if as an adult neurologist you encounter someone with, you know, residual tubing from one of these procedures, you are unlikely to need to do anything about it. So, we put in ventricular access device or ventriculosubgaleal shunts, usually in newborns or infants. And sometimes when they no longer need the device, we just leave it in because that saves them an extra surgery. So, if you encounter one later on, it's most likely you won't need to do anything. Often if the baby goes on to show that they need a permanent shunt, we go ahead and put in that permanent shunt. We may or may not go back and take out the reservoir or the subgaleal shunt. The reservoir and subgaleal shunts are often put in the frontal location. Sometimes we'll put the permanent shunt in the occipital location and just leave the residual tubing there. So, you're very unlikely to need to intervene with a reservoir or subgaleal shunt if you encounter an older child or adult with that left in. We use these in the small babies because the external ventricular drains that we're very familiar with have a very high complication rate in this population. In the adult ICU, you often see these, and maybe there's, you know, a few percent risk of infection. It actually heads into 20 to 25% in our preterm infants and other newborns that require one of these devices for drainage. So, we try not to use external ventricular drains like we use in older patients. We use the internalized device: either the ventricular reservoir with a little area for us to tap every day, every other day; or the ventriculosubgaleal shunt, which diverts the spinal fluid to a pocket in the scalp. So, we use these in preterm infants that are too tiny for a permanent shunt. And for some of our babies that are born, for example, with an omphalocele, that we can't use their peritoneal cavity and so we need some temporizing device to manage their CSF. Dr Albin: Totally makes sense. And so just to clarify, I mean, this is a tube that's placed into the ventricles of the brain and then it's tunneled into the subgaleal space and the collection, the CSF, just builds up there, like? Dr Robinson: Yeah. Dr Albin: And over time either, you know, the baby will learn how to account for that extra CSF, and then I guess it's just reabsorbed? Dr Robinson: Yeah. When it's present, though, it looks like maybe, I don't know if you're familiar with like a tissue expander. There is this bubble of fluid under the scalp, but it's prominent, it can be several centimeters in diameter. Dr Albin: Wow, that's just absolutely fascinating. And I don't think I've ever had the opportunity to see this in clinical practice. I've really learned quite a bit about this. I assume that these children are going to go on to get some sort of permanent diversion. And then, you know, over time, those permanent shunts do create a lot of problems. And so, I was hoping you could kind of walk us through, you know, what are some of the things that you're seeing that you're concerned about? And then if you've just inherited a patient who had a shunt placed at, say, a different institution, how do you go about figuring out what kind of shunt it is and if they're still dependent on it? Dr Robinson: There's a few things that, fortunately, technology is helping with. So, it is much easier now for patients to get their images uploaded to image-sharing software, and then we can download their images into our institutional software, which is very helpful. Another option is that we are strongly encouraging our families to use a app such as HydroAssist that's available from the Hydrocephalus Association. So that's an app that goes on your phone, and you can upload the images from an MRI or a CT scan or x-rays from a shunt series. And then that you can take if you're traveling and you have to go to emergency department or you're establishing care with a new provider, you can have your information right there and not be under stress to remember it. It also has areas so you can record the type of valve. And all of our valves have pluses and minuses, they all tend to malfunction a little bit. And they can be particularly helpful with different types of hydrocephalus. I really doubt that we're going to narrow down from the fifteen or so valves we have access to now. And so, recording your valve type, the manufacturer as well as the setting, is very helpful when you're transferring care or if you're traveling and then have to, unfortunately, stop in the emergency department. Dr Albin: Yeah, I thought that was a really great pearl that, like, families now are empowered to sort of take control of understanding sort of the devices that they have, the settings that they're using. And what an incredible thing for providers who are going to care for these patients who, you know, unfortunately do end up in centers that are not their primary center. The other challenge that I find… I practice as a neurointensivist, and sometimes patients come in and they have a history of being shunt dependent and they present with a neurologic change. And I think that we as neurologists can be a little quick to blame the shunt and want the shunt to be tapped. And I was really struck in reading this article about the complexity of shunt taps. And I was hoping, you know, can you kind of walk us through what's involved and maybe why we should have a little bit of a higher threshold before just saying, ah, just have the neurosurgeons tap the shunt. Like, it's not that straightforward. Dr Robinson: And it may depend on the population you're caring for. So, when I was at a different institution, we actually published that there's about a 5% complication rate from shunt taps. And that may be- that was in pediatric patients. And again, that may be population dependent, but you can introduce infection to a perfectly clean shunt by doing a shunt tap. You can also cause an acute shunt malfunction. So that's why we tend to prefer that only neurosurgeons are doing shunt taps for evaluation of a shunt malfunction. There are times that, for example, our patients who are getting intrathecal chemotherapy or something have a CSF access device like an Ommaya reservoir, and other providers may tap that reservoir to instill medicine. But that's different than an evaluation, like, you're talking about somebody with a neurological change. And so, it is possible that if somebody has small ventricles or something, if you tap that shunt, you can take a marginally functioning shunt and turn it into an acute proximal malfunction, which is an emergency. Dr Albin: Absolutely. I think that's a fantastic pearl for us to take away from this. It's just that heightened level. And kind of on the flip side of that, you know, and I really- I do feel for us when we're trying to kind of, you know, make a case that it's, it's not the shunt. Many of our shunted patients also have a lot of neurologic complexity, which I think you really talked upon in this article. I mean, these are patients who have developmental cognitive delays and that they have epilepsy and that they're at risk for, you know, complications from prematurity, since that's a very common reason that patients are getting shunts. But from your experience as a neurosurgeon, what are some of the features that make you particularly concerned about shnut malfunction? And how do you sort of evaluate these patients when they come in with that altered mental status? Dr Robinson: It is challenging, especially for our patients that have, you know, some intellectual delay or other difficulties that make it hard for them to give an accurate history. Problem is, if they're sick and lethargic, they may not remember the symptoms that they had when they were sick. But sometimes there's hopefully there's a family member present that does remember and can say, oh, no, this is what they look like when they have a viral illness. And this is different from when they have the shot malfunction, which was projectile emesis, not associated with a fever. It's rare to have a fever with a shunt malfunction, although shunt infection often presents with malfunction. So, it's not completely exclusionary. We often look at the imaging, but it's taking the whole picture together. Some of the common other diagnoses we see are severe constipation that can decrease the drainage from the shunt and even cause papilledema in some people. So, we look at that as well on the shunt series. It's very important to have the shunt series if you're concerned about shunt malfunction or- the shunt tubing is good. It tends to last maybe 20to 25 years before it starts to degrade. And so, you may have had a functioning shunt for decades and it worked well and you're very dependent on it, and then it breaks and you become ill. But on the flip side, we have patients that have had a broken shunt for years, they just didn't know about it. And we don't want to jump in and operate on them and then cause complexities. And so, it is a challenge to sort out. The simplest thing is obviously if they come in and their ventricles are significantly larger, and that goes along with a several-hour or a couple-day deterioration, that's a little more clear-cut. Dr Albin: Absolutely. And you talked about this shunt series. What other imaging- and, sort of maybe walk us through, what's involved in a shunt series, what are you looking at? And then what other imaging is sort of your preferred method for evaluating these patients? Dr Robinson: In adult patients, the shunt series is the x-ray from the entire shunt. And so, if they have an atrial shunt, that would be skull x-ray plus a chest x-ray; or the shunt ends in the perineal cavity, it goes to the perineum. And we're looking for continuity. We're looking for the- sometimes as people grow and age, the ventricular catheter can pull out of the ventricle. So, we're looking to make sure that the ventricular catheter is in an optimal position relative to the skull. We can also look at the valve setting to see the type of valve. So, that can also be helpful as well. And then in terms of additional imaging, a CT scan or an MRI is helpful. If you don't know what type of valve they have, they should not, ideally, go in the MRI scanner. We like to know what their setting is before they go in the MRI because we're going to have to reset the valve after they come out of the MRI if it's a programmable valve. Dr Albin: This is fantastic. I've heard several pearls. So, one is that with the shunt series, which, am I correct in understanding those are just plain X-rays? Dr Robinson: Yes. Dr Albin: Right. Then we can look for constipation, and that might be actually something really serious in a pediatric patient that could clue us in that they could actually be developing hydrocephalus or increased ICP just because of the abdominal pressure. And then that we need to be mindful of what are the stunt settings before we expose anyone to the MRI machine. Is that two good takeaways from all of this? Dr Robinson: Yes. And it's very rare that there'll be an MRI tech that will allow a patient with a valve in the MRI without knowing what it is. So, they have their job security that way. But yeah, if you're not sure, just go ahead and get the CT. Obviously, in our younger kids, we're trying to avoid CT scans. But if you're weighing off trying to decide if somebody has a shunt malfunction versus, you know, waiting 12 or 24 hours for an MRI, go ahead and get the CT. Dr Albin: Absolutely. I love it. Those are things I'm going to take with me for this. I have one more question about these shunts. So, every now and then, and I think you started to touch on this, we will get a shunt series and we'll see that the catheter is fractured. Do the patients develop little- like, a tract that continues to allow diversion even though the catheter is fractured? Dr Robinson: Yes. So, they can develop scar tissue around, and some people have more scar tissue than others. You'll even see that sometimes, say, the catheter has fractured and we'll take out that old fractured tubing and put in new tubing on the other side. But if you go and palpate their neck or chest, you'll still feel that tract is there because it calcifies along the tract. Some patients drain through that calcified tract for weeks or months without symptoms, and then it can occlude off. So, we don't consider it a reliable pathway. It's also not a reliable pathway if you're positioned prone in the OR. So some of our orthopedic colleagues, for example, if they go to do a spine fusion, we like to confirm that the shunt is working before you undergo that long anesthesia, but also that you're going to be positioned prone and you could potentially- you know, the pressure could occlude that track that normally is open. Dr Albin: This is fantastic. I feel like I've gotten everything I've ever wanted to know about shunts and all of their complications in this, which is, you know, this is really difficult. And I think that because we are not trained to put these in, sometimes we see them and we just say, oh, it's fractured that must be a malfunction. But it's good to know that sometimes those patients can drain through, you know, a sort of scarred-down tract, but that it may not be nearly as reliable as when they have the tubing in place. Another really good thing that I'm going to put in my back pocket for the next time I see a patient with a potential shunt malfunction. Dr Robinson: And we do have some patients that the tubing is fractured years ago and they don't need it repaired, and that totally can be challenging when they then transfer to your practice for follow-up care. We tend to follow those patients very closely, both our clinic visits as well as having them seen by ophthalmology. So, there are teenagers and young adults out there that have… their own system has recovered and they are no longer shunt-dependent; and they may have a broken shunt and not actually be using that track, but they usually have had fairly intensive follow up to prove that they're not shunt-dependent. And we still have a healthy respect there that, you know, if they start to get a headache, we're going to take that quite seriously as opposed to, you know, some of our shunt patients, about 10 to 20%, have chronic headaches that are not shunt-related. So, not everybody who has a headache and has a shunt has a shunt malfunction. It's tough. Dr Albin: This is really tough. That actually brings me to sort of the last clinical scenario that I was hoping we could get your perspective on. And I think this would be of great interest to neurologists, especially in the context that these children may develop headaches that have nothing to do with the shunt. I'd like to sort of give you this hypothetical case that I'm a neurologist seeing a patient in clinic and it's a teenager, maybe a young adult, and they had a shunt placed early in childhood. They've done really well. And they've come to me for management of a new headache. And, you know, as part of this workup, their primary care provider had ordered an MRI. And, you know, I look at the MRI, and I don't think that the ventricles look really enlarged. They don't look overdrained. Is having an MRI that looks pretty okay, is that enough to exonerate the shunt in this situation? Dr Robinson: In most cases it is. The one time that we don't see a substantial change in the ventricles is if we have a pseudocyst in the abdomen. The ventricles cannot enlarge initially, and then later on they might enlarge. So, we see that sometimes that somebody will come in and their ventricles will be stable in size, but we're still a little bit suspicious. They've got this persistent headache. They may have, you know, some emesis or loss of appetite, loss of activity, and a slower presentation than you would get with an acute proximal malfunction. We can check an abdominal ultrasound for them. And sometimes, even though the ventricles haven't changed in size, they still have a malfunction because they have that distal pseudocyst. One of the questions that we ask our patients when we're establishing care, in addition to what valve type they have and what sort of their shunt history or other interventions such as endoscopic third ventriculostomy, is to ask if their ventricles enlarge when they have a shunt malfunction. There is a small fraction where they do not. They kind of have a stiff brain, if you will. And so, it's good to know that. That's one of the key factors is asking somebody, do the ventricles enlarge when they have a malfunction? If they have enlarged in the past, they're likely to enlarge again if they have a malfunction. But again, it's not 100%. So, in peds, 20% of the time the ventricles don't enlarge. So, in adults, I'm not that- you know, I don't know what percentage it is, but it's something to consider that you can have a stable ventricular size and still have a shunt malfunction. So, if your clinical judgment, you're just kind of, like, still uneasy, you know, respect that and maybe do a little more workup. That's why we so much want patients to establish care with somebody, whether it's a neurologist or a neurosurgeon or other provider in some areas that have fewer neurospecialists, but to establish care so that you all know what a change is for that patient. That's really important. Dr Albin: That's fantastic. So, to summarize that, it's really important to understand the patient's baseline and how they presented with prior shunt complications, if they've had some. That if they're coming in with a new headache that we don't have a baseline, so, we should just have a heightened level of awareness that, like, the shunt has a start and it has an end. And even if the start of the shunt in the brain looks okay, there still could be the potential for complications in the abdomen. And maybe the third thing I heard from that is that we should look for GI symptoms and sort of be aware of when there could be a complication in the abdomen as well. Does that all sound about right? Dr Robinson: And especially for our kids with spina bifida and for posthemorrhagic hydrocephalus are now adults, because the preterm infants are prone to necrotizing enterocolitis. And they may not have had surgery for it, but they still may have adhesions and other things that predispose them to develop pseudocysts over time. And then our individuals with spina bifida often have various abdominal surgeries and other procedures to help them manage their bowel and bladder function. And so that can also create adhesions that then predisposes to pseudocysts. So, we do have a healthy respect for that. In addition, it used to be---because we have gotten a little better with shunts over time---it used to be, like, when I was in training that you heard, you know, if you haven't had a shunt malfunction for 10 or 15 years, you must- you may no longer be dependent. And that's not really true. There are some people who outgrow their need for shunt dependence, but not everyone does outgrow it. And so, you can be 15, 20 years without a shunt revision and still be shunt-dependent. Dr Albin: Those are fantastic pearls. I think most of them, walking away with this, like, a very healthy respect for the fact that these are complex patients, which the shunt is one component of sort of the things that can go wrong and that we have to have a really healthy respect and really detailed investigation and sort of take the big picture. I really like that. Dr Robinson: Yeah, I know. I think it's- there's a very strong push amongst pediatric neurosurgery and a lot of the related, our colleagues in other areas, to develop multidisciplinary transition clinics and lifespan programs for these patients to help keep everything else optimized so that they're not coming in, for example, with seizures. But then you have to figure out if this is a seizure or a shunt; you know, if we can keep them on track, if we can keep them healthy in all their other dimensions, it makes it safer for them in terms of their shunt malfunction. Dr Albin: Absolutely. I love that, and just the multidisciplinary preventative aspect of trying to keep these patients well. So important. Dr Robinson, I really would like to thank you for your time. We're getting towards the end of our time together. Are there any other points about the article that you just are anxious that leave the readers with, or should I just direct them back to the fantastic review that you've put together on this topic? Dr Robinson: No, I think that we covered a lot of the high points. I think one of the really exciting things for hydrocephalus is that there's a lot of investigations into other options besides shunts for certain populations. We are seeing less hydrocephalus now with the fetal repair of the myelomeningocele, which is great. And we're trying to make inroads into posthemorrhagic hydrocephalus as well. So, there are a lot of great things on the horizon and, you know, hopefully someday we won't have the need to have these discussions so much for shunts. Dr Albin: I love it. I think that's really important. And all of those points were touched on the article. And so, I really invite our listeners to go and check out the article, where you can see sort of, like, how this is evolving in real time. Thank you, Dr Robinson. Please go and check out the childhood-onset hydrocephalus article, which appears in the most recent issue of Continuum on the disorders of CSF dynamics. And be sure to check out Continuum Audio episodes from this and other issues. Thank you again to our listeners for joining us today. And thank you, Dr Robinson. Dr Robinson: Thanks for having me. Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

A patient walks in with a persistent runny nose. Is it allergies, or something more dangerous? In this episode of the BackTable ENT Podcast, two renowned rhinologists, Dr. Satyan Sreenath and Dr. Sanjeet Rangarajan, delve into the evaluation and management of cerebrospinal fluid (CSF) leaks at the anterior skull base with host Dr. Gopi Shah. --- SYNPOSIS The discussion encompasses patient presentations, differential diagnosis, physical examination, and imaging techniques for localization. They also explore the impact of underlying conditions such as idiopathic intracranial hypertension (IIH) and obstructive sleep apnea (OSA) on CSF leaks. Dr. Sreenath and Dr. Rangarjan offer insight into diagnostic strategies, patient management, and surgical planning, providing a comprehensive overview of best practices in managing this complex condition. --- TIMESTAMPS 00:00 - Introduction 02:48 - Patient Presentation and Initial Evaluation04:45 - Common Symptoms and Diagnostic Challenges06:02 - Risk Factors and Etiologies of CSF Leaks10:59 - Management and Treatment Approaches16:55 - Physical Examination and Diagnostic Techniques22:35 - Patient Instructions for Sample Collection24:29 - Differentiating CSF Leaks from Other Conditions26:12 - Endoscopic Examination Techniques30:21 - Imaging and Diagnostic Approaches33:14 - Surgical Planning and Considerations45:23 - Concluding Thoughts --- RESOURCES Satyan Sreenath https://iuhealth.org/find-providers/provider/satyan-b-sreenath-md-1821999 Sanjeet Rangarajan https://www.uhhospitals.org/doctors/Rangarajan-Sanjeet-1649568395

Fred Bird and Kaleigh Leager, Assistant Manager, Mid-Atlantic States for the Congressional Sportsmen's Foundation cover this week's conservation news, including the recent victories for Sunday Hunting in Pennsylvania which Kaleigh joins us for. The conversation highlights the importance of bipartisan support in conservation efforts, the role of key figures like Pennsylvania Governor Shapiro and bipartisan support in the Legislatures, and the ongoing challenges faced in wildlife management and habitat restoration. Fred then turns to the rest of the news from around the nation including a wrap-up of the One Big Beautiful Bill, Crossbows in Minnesota, and much more.   Key Takeaways Governor Shapiro of Pennsylvania's support for sportsmen is a positive sign for future legislation. The One Big Beautiful Bill has significant implications for sportsmen. The removal of the $200 tax stamp for suppressors is a major win. CSF's representation in Washington ensures sportsmen's voices are heard. President Trump's Make America Beautiful Again executive order aims to bolster conservation efforts. Crossbows are now fully included in Minnesota's archery season. Wildlife habitat restoration projects in North Carolina are moving forward. Active management of public lands is crucial for wildlife health.   Get the FREE Sportsmen's Voice e-publication in your inbox every Monday: www.congressionalsportsmen.org/newsletter   Sign up for FREE legislative tracking through CSF's Tracking the Capitols tool: www.congressionalsportsmen.org/tracking-the-capitols/ Learn more about your ad choices. Visit megaphone.fm/adchoices

Normal pressure hydrocephalus (NPH) is a pathologic condition whereby excess CSF is retained in and around the brain despite normal intracranial pressure. MRI-safe programmable shunt valves allow for fluid drainage adjustment based on patients' symptoms and radiographic images. Approximately 75% of patients with NPH improve after shunt surgery regardless of shunt type or location. In this episode, Aaron Berkowitz, MD, PhD, FAAN, speaks with Kaisorn L. Chaichana, MD, author of the article “Management of Normal Pressure Hydrocephalus” in the Continuum® June 2025 Disorders of CSF Dynamics issue. Dr. Berkowitz is a Continuum® Audio interviewer and a professor of neurology at the University of California San Francisco in the Department of Neurology in San Francisco, California. Dr. Chaichana is a professor of neurology in the department of neurological surgery at the Mayo Clinic in Jacksonville, Florida. Additional Resources Read the article: Management of Normal Pressure Hydrocephalus Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Host: @LyellJ Guest: @kchaichanamd Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. Dr Berkowitz: This is Dr Aaron Berkowitz, and today I'm interviewing Dr Kaisorn Chaichana about his article on management of normal pressure hydrocephalus, which he wrote with Dr Jeremy Cutsforth-Gregory. The article appears in the June 2025 Continuum issue on disorders of CSF dynamics. Welcome to the podcast, and please introduce yourself to our audience. Dr Chaichana: Yeah, thank you for having me. I'm Kaisorn Chaichana. I'm a neurosurgeon at Mayo Clinic in Jacksonville, Florida. Part of my practice is doing hydrocephalus care, which includes shunts for patients with normal pressure hydrocephalus. Dr Berkowitz: Fantastic. Well, before we get into shunt considerations and NPH specifically, which I know is the focus of your article, I thought it would be a great opportunity for a neurologist to pick a neurosurgeon's brain a bit about shunts. So, to start, can you lay out for us the different types of shunts and shunt procedures, the advantages, disadvantages of each type of shunt, how you think about which shunt procedure should be used for which patient, that type of thing? Dr Chaichana: Yeah. So, there are different types of shunts, and the most common one that is used is called a ventricular peritoneal shunt. So, it has a ventricular catheter, it has a catheter that tunnels underneath the skin and it goes into the peritoneum where the fluid goes from the ventricular system into the peritoneum. Typically, the shunts are in the ventricle because that is the largest fluid-filled space in the brain. Other terminal areas include the atrium, which is really the jugular vein, and those are called ventricular atrial shunts. You can also have ventricular pleural shunts, which end in the pleural space and drain flui into the pleural space. Those are pretty much the most common ventricular shunts. There's also a lumboperitoneal shunt that drains from the lumbar spine, similar to a lumbar drain into the peritoneum. For the lumbar shunts, we don't typically have a lumbar pleural or lumbar atrial shunt just because of the pressure dynamics, because the lumbar spine is below the lung and as well as the atrium. And so, the drainage pattern is very different than ventricular peritoneal which is top to bottom. The most common shunt, why we use the ventricular peritoneal shunt the most, is because it has the most control. So, the peritoneum is set at a standard pressure in the intraabdominal pressure, whereas the ventricular atrial shunt depends on your venous return or venous pressure and your ventricular pleural shunt varies with inspiration and expiration. So, the easiest way for us to control the fluid, the ventricular system is through the ventricular peritoneal shunt. And that's why that's our most common shunt that we use. Dr Berkowitz: Fantastic. So, as you mention in the article, neurologists may be reluctant to offer a shunt to patients with NPH because many patients may not improve, or they improve only transiently; and out of fear of shunt complications. So, of course, as neurologists, we often only hear about a patient's shunt when there is a problem. So, we have this sort of biased view of seeing a lot of shunt malfunction and shunt infection. Of course, we might not see the patient if their shunt is working just fine. How common are these complications in practice, and how do you as a neurosurgeon weigh the risks against the often uncertain or transient benefits of a shunt in a patient with NPH who may be older and multiple medical comorbidities? How do you think about that and talk about it with patients? Dr Chaichana: When you hear about shunt complications, most of the shunt complications you hear about are typically in patients with congenital hydrocephalus. Those patients often require several shunt revisions just from either growing or the shunt stays in for a long time or the ventricular caliber is a lot less than some with normal pressure hydrocephalus. So, we don't really see a lot of complications with normal pressure hydrocephalus. So that shunt placement in these patients is typically pretty safe. The procedure's a relatively short procedure, around 30 minutes to 45 minutes to place a shunt, and we can control the pressure within the shunt setting so that we don't overdrain---which means too much fluid drains from the ventricular system---which can cause things like a subdural, which is probably the most common complication associated with normal pressure hydrocephalus. So, to obviate those risks, what we do is typically insert the shunt and then keep the shunt setting at a high setting. The higher the setting, the less it drains, and then we bring it slowly down based on the patient's symptoms to try to minimize the risk of this over drainage in the subdural hematoma while at the same time benefiting the patient. So, there's a concern for shunt in patients with normal pressure hydrocephalus. The concern or the complication risks are very low. The problem with normal pressure hydrocephalus, though, is that over time these patients benefit less and less from drainage or their disease process takes over. So, I do recommend placing this shunt as soon as possible just so that we can maximize their quality of life for that period of time. Dr Berkowitz: So, if I'm understanding you, then the risk of complication is more sort of due to the mechanical factors in patients with congenital hydrocephalus or sort of outgrowing the shunt, their pressure dynamics may be changing over time. And in your experience, an older patient with NPH, although they may have more medical comorbidities, the procedure itself is relatively quick and low-risk. And the actual complications due to mechanical factors, my understanding, are just much less common because the patient is obviously fully grown and they're getting one sort of procedure at one point in time and tend to need less revision, have less complication. Is that right? Dr Chaichana: Yeah, that's correct. The complication risk for normal hydrocephalus is a lot less than other types of hydrocephalus. Dr Berkowitz: That's helpful to know. While we're talking about some of these complications, let's say we're following a patient in neurology with NPH who has a shunt. What are some of the symptoms and signs of shunt malfunction or shunt infection? And what are the best studies to order to evaluate for these if we're concerned about them? Dr Chaichana: Yeah. So basically, for shunt malfunction, it's basically broken down into two categories. It's either overdrainage or underdrainage. So, underdrainage is where the shunt doesn't function enough. And so basically, they return to their state before the shunt was placed. So that could be worsening gait function, memory function, urinary incontinence are the typical symptoms we look for in patients with normal pressure hydrocephalus and underdrainage, or the shunt is not working. For patients that are having overdrainage, which is draining too much, the classic sign is typically headaches when they stand up. And the reason behind that is when there's overdrainage, there's less cerebrospinal fluid in their ventricular system, which means less intracranial pressure. So that when they stand up, the pressure differential between their head and the ground is more than when they're lying down. And because of that pressure differential, they usually have worsening headaches when standing up or sitting up. The other thing are severe headaches, which would be a sign of a subdural hematoma or focality in their neurological symptoms that could point to a subdural hematoma, such as weakness, numbness, speaking problems, depending on the hemisphere. How we work this up is, regardless if you're concerned about overdrainage or underdrainage, we usually start with a CAT scan or an MRI scan. Typically, we prefer a CAT scan because it's quicker, but the CAT scan will show us if the ventricular caliber is the same and/or the placement of the proximal catheter. So, what we look for when we see that CAT scan or that MRI to see the location of the proximal catheter to make sure it hasn't changed from any previous settings. And then we see the caliber of the ventricles. If the caliber of the ventricles is smaller, that could be a sign of overdrainage. If the caliber of the ventricles are larger, it could be a sign of underdrainage. The other thing we look for are subdural fluid collections or hydromas or subdural hematomas, which would be another sign of lower endocranial pressure, which would be a sign of overdrainage. So those are the biggest signs we look for, for underdrainage and overdrainage. Other things we can look for if we're concerned of the shunt is fractured, we do a shunt X-ray and what a shunt x-ray is is x-rays of the skull, the neck and the abdomen to see the catheter to make sure it's not kinked or fractured. If you're really concerned, you can't tell from the x-ray, another scan to order is a CT of the chest and abdomen and pelvis to look at the location of the catheter to make sure there's no brakes in the catheter, there's no fluid collections on the distal portion of the catheter, which would be a sign of shunt malfunction as well. Other tests that you can do to really exclude shunt malfunction is a shunt patency test, and what that is a nuclear medicine test where radionucleotide is injected into the valve and then the radionucleotide is traced over time or imaged through time to make sure that it's draining appropriately from the valve into the distal catheter into the peritoneum or the distal site. If there's a shunt malfunction that's not drainage, that radioisotope would remain stagnant either in the valve or in the catheter. There's overdrainage, we can't really tell, but there will be a quick drainage of the radioisotope. For shunt infection, we start with an imaging just to make sure there's not a shunt malfunction, and that usually requires cerebrospinal fluid to test. The cerebrospinal fluid can come from the valve itself, or it can come from other areas like the lumbar spine. If the lumbar spine is showing signs of shunt infection, then that usually means the shunt is infected. If the valve is aspirated with- at the bedside with a butterfly needle into the valve and that shows signs of shunt infection, that also could be a sign of infection. Dr Berkowitz: That's very helpful. You mentioned CT and shunt series. One question that often comes up when obtaining neuroimaging in patients with a shunt, who have NPH or otherwise, is whether we need to call you when we're doing an MRI to reprogram the shunt before or after. Is there a way we can know as a neurologists at the bedside or as patients carry a card, like with some devices where we know whether we have to call and bother our neurosurgery colleagues to get this MRI? Or if the radiology techs ask us, is this safe? And is the patient's shunt going to get turned off? How do we go about determining this? Dr Chaichana: Yeah, so unfortunately, a lot of patients don't carry a card. We typically offer a card when we do the shunt, but that card, there's two problems with it. One is it tells the model, but the second thing is it has to be updated any time the shunt is changed to a different setting. Oftentimes patients don't know that shunt setting, and often times they don't know that company brand that they use. There are different types of shunts with different types of settings. If there's ever concern as to what type of shunt they have, an x-ray is usually the best bet to see with a shunt series, or a skull x-ray. A lateral skull x-ray usually looks at the valve, and the valve has certain radio-dense markers that indicate what type of shunt it is. And that way you can call neurosurgery and we can always tell you what the shunt setting is before the MRI is done. Problem with an MRI scan if you do it without a shunt x-ray before is that you don't know the setting before unless the patient really knows or it's in the patient chart, and the MRI can need to change the setting. It doesn't usually turn it off, but it would change the setting, which would change the fluid dynamics within their ventricular system, which could lead to overdrainage or underdrainage. So, any time a patient needs MRI imaging, whether it's even the brain MRI, a spine MRI, or even abdominal MRI, really a shunt x-ray should be done just to see the shunt setting so that it could be returned to that setting after the MRI is done. Dr Berkowitz: So, the only way to know sort of what type of shunt it would be short of the patient knowing or the patient getting care at the same hospital where the shunt was placed and looking it up in the operative reports would be a skull film. That would then tell us what type of shunt is there and then the marking of the setting. And then we would be able to call our colleagues in neurosurgery and say, this patient is getting an MRI this is the setting, this is the type of shunt. And do we need to call you afterwards to come by and reprogram it? Is that right? Dr Chaichana: That's correct, yeah. Dr Berkowitz: Is there anything we would be able to see on there, or it's best we just- best we just call you and clarify? Dr Chaichana: The easiest thing to do is, when you get the skull x-ray, you can Google different types of shunts or search for different shunts, and they'll have markers that show the type of shunt it is as well as the setting that it's at. And just match it up with the picture. Dr Berkowitz: And as long as it's not a programmable shunt, there's no concern about doing the MRI. Is that right? Dr Chaichana: Correct. So, if it's a programmable shunt, even if it's MRI-compatible, we still like to get the setting before and make sure the setting after the MRI is the same. Nonprogrammable shunts can't be changed with MRI scans, and those don't need neurosurgery after the MRI scan, but it should be confirmed before the scan is done. Dr Berkowitz: Very helpful. Okay, so let's turn to NPH specifically. As you know, there's a lot of debate in the literature, some arguing, even, NPH might not even exist, some saying it's underdiagnosed. I think. I don't know if it was last year at our American Academy of Neurology conference or certainly in recent years, there was a pro and con debate of “we are underdiagnosing NPH” versus “we are overdiagnosing NPH.” What's your perspective as a neurosurgeon? What's the perspective in neurosurgery? Is this something we're underdiagnosing, and the times you shunt these patients you see miraculous results? Is this something that we're overdiagnosing, you get a lot of patients sent to that you think maybe won't benefit from a shunt? Or is it just really hard to say and some patients have shunt-responsive noncommunicating hydrocephalus of unclear etiology and either concurrent Parkinson's disease, Alzheimer's, cervical lumbar stenosis, neuropathy, vestibular problems, and all these other issues that play into multifactorial gait to sort of display a certain amount of the percentage of problem in a given patient or take overtime? What's your perspective if you're open to sharing it, or what's the perspective of neurosurgery? Is this debated as it is in neurology or this is just a standard thing you see and patients respond to shunt to some degree in some proportion of the time? And what are the sort of predictors you see in your experience? Dr Chaichana: Yeah, so, for me, I'd say it's too complicated for a neurosurgeon to evaluate. We rely on neurology to tell us whether or not they need a shunt. But I think the problem is, obviously, a part of the workout for at least the ones that I like to do, is that I want them to have a high-volume lumbar puncture with pre- and postgait analysis to see if there's really an objective measure of them improving. If they have an objective measure of improvement---and what's even better is that they have a subjective measure of improvement on top of the objective measure of improvement---then they benefit from a shunt. The problem is, some patients do benefit even though they don't have objective performance increases after a high-volume shunt. And those are the ones that make me the most worrisome to do the shunt, just because I don't like to do a procedure where there's no benefit for the patient. I do see, according to the literature as well, that there's around a 30 to 40%, even 50%, increase in gait function, even in patients that don't have large improvements following the high-volume lumbar puncture. And those are the most challenging patients for us as neurosurgeons because we'll put the shunt in, they say we're no better in terms of their gait, no better in terms of their urinary incontinence. We try to lower their shunt down to a certain setting and we're kind of stuck after that point. The good thing about NPH, though, is that, from the neurosurgery side, the shunt, like I said, is a pretty benign, low-risk procedure. So, we're not putting the patient through a very severe procedure to see if there's any benefit. So, in cases where we try to improve their quality of life in patients that don't have a benefit from high-volume lumbar puncture, we give them the odds of whether or not it's improving and say it might not improve. But because the procedure's minimally invasive, I think it's a good way to see if we can benefit their quality of life. Dr Berkowitz: Yeah, it's a very helpful perspective. Yeah, those are the most challenging cases on our side as well, right. If the patient- we think they may have NPH, or their gait and/or urinary and/or cognitive problems are- at least have a component of NPH that could be reversible, we certainly want to do the large volume lumbar puncture and/or consider a lumbar drain trial, all discussed in other articles and interviews for this issue of Continuum, But the really tough ones, as you said, there is this literature on patients who don't respond to the large-volume lumbar puncture for some reason but still may be shunt responsive. And despite all the imaging predictors and all the other ways we try to think about this, it's hard to know who's going to benefit. I think that's really a helpful perspective from your end that, as you say in the very beginning of your article, right, maybe there's a little bit too much fear of shunting on the neurology side because when we hear about shunts, it's often in the setting of complication. And so, we're not sort of getting the full spectrum of all the patients you shunt and you see who are doing just fine. They might not improve---the question is related to NPH---but at least they're not harmed by the shunt, and we're maybe overbiased and/or seeing a overly representative sample of negative shunt outcomes when they're actually not that common in practice. Is that a fair summary of your perspective? Dr Chaichana: Yeah, that's correct. So, I mean, complications can occur---and anytime you do a surgery, there are risks of complications---but I think they're relatively low for the benefit that we can help their quality of life. And the procedure's pretty short. So, the risk, it mostly outweighs the benefits in cases with normal pressure hydrocephalus. Dr Berkowitz: Very helpful perspective. So, well, thanks so much again. Today I've been interviewing Dr Kaisorn Chaichana about his article on management of normal pressure hydrocephalus, which he wrote with Dr Jeremy Cutsforth-Gregory. This article appears in the most recent issue of Continuum on disorders of CSF dynamics. Be sure to check out Continuum Audio episodes from this and other issues, and thank you to our listeners for joining us today. Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

Sunday hunting is officially expanding in Connecticut and Pennsylvania, marking a major victory for hunters, conservationists, and rural communities. In this episode, Fred is joined by representatives of each state's fish and wildlife agency to break down the new legislation that opens up Sunday hunting opportunities, explore how it impacts hunter access, and discuss what it means for the future of hunting and wildlife conservation.   Steve Smith, Executive Director of the Pennsylvania Game Commission joins us to look at Pennsylvania's recent rescinding of the Sunday hunting prohibition in PA, tracing the decades-long legislative battle and the positive ripple effects it's already creating for hunters and wildlife management.   Jenny Dickson, Director of Wildlife, Bureau of Natural Resources, Connecticut Department of Energy and Environmental Protection then joins the show to share insights on the Connecticut Sunday hunting bill, its potential to boost youth hunting participation, and how it benefits local economies tied to the hunting and fishing industry.   Whether you're passionate about deer hunting, turkey hunting, or waterfowl hunting, this conversation explains how expanded hunting days can help sportsmen and women spend more time in the field, strengthen family traditions, and contribute even more to conservation funding.   Key Takeaways for Hunters and Anglers: CSF has been a leading champion of removing restrictions on Sunday hunting for well over a decade – passing over 20 pro-Sunday hunting bills in 9 states. Sunday hunting legislation expands hunting opportunities for deer, turkey, small game, and more. Youth hunting participation is vital for the future of hunting traditions and conservation funding. Sportsmen and women contribute significant revenue to conservation efforts through license fees and excise taxes. The economic impact of hunting reaches far beyond license sales, benefiting local outfitters, retailers, and tourism businesses. Connecticut's new Sunday hunting law takes effect October 1st. Waterfowl hunting regulations remain unchanged despite the new law in Connecticut. Hunters must secure landowner permission before hunting on private land, in Connecticut. More flexible hunting days help optimize hunting strategies and time afield. Pennsylvania's Sunday hunting law is expected to boost hunter participation and conservation dollars. Decades-long legislative efforts led to successful Sunday hunting legalization in Pennsylvania. Expanded hunting days support better wildlife management and sustainable game populations. Repealing Sunday hunting restrictions provide families more time to hunt together and introduce new hunters to the outdoors. Connecticut and Pennsylvania could become models for other states considering Sunday hunting bills. Get the FREE Sportsmen's Voice e-publication in your inbox every Monday: www.congressionalsportsmen.org/newsletter                Sign up for FREE legislative tracking through CSF's Tracking the Capitols tool: www.congressionalsportsmen.org/tracking-the-capitols/ Learn more about your ad choices. Visit megaphone.fm/adchoices

Fred Bird and Christian Ragosta are in studio this week to break down the latest wins and challenges in conservation policy and sportsmen's rights, including celebrating major victories with the repeal of Sunday hunting restrictions in both Pennsylvania and Connecticut—a significant milestone for hunters seeking expanded access and opportunities in both, the Keystone State and Nutmeg State. Christian shares insights into how strong legislative support from the Sportsmen's Caucus in Connecticut helped drive these changes across the finish line.   But it's not all good news. The conversation turns to Rhode Island, where a controversial “assault weapons” ban has sparked heated debate. Fred and Christian examine the political motivations behind the legislation, the contentious registration requirements, and the ripple effects it could have on conservation funding and non-resident hunting participation. They also discuss the possibility that the law could end up before the Supreme Court. Key Takeaways Sunday Hunting Wins: Pennsylvania and Connecticut have repealed longstanding bans on Sunday hunting—a significant success for sportsmen's access and opportunity. Role of the Sportsmen's Caucus: Christian Ragosta highlights how the Connecticut Sportsmen's Caucus played a crucial role in supporting pro-hunting legislation. Rhode Island's Assault Weapons Ban: Reflects a broader trend of states pursuing similar gun control measures, while it raises concerns about the motivations behind the legislation and its potential impacts on lawful hunters and conservation funding. Non-resident hunters may be particularly affected by new regulations. Ongoing Advocacy is Key: Hunters and conservation advocates must remain vigilant and proactive to protect access and ensure sustainable funding for wildlife and habitat management. Supreme Court Watch: The potential for legal challenges to Rhode Island's law could set significant precedents for sportsmen nationwide.   Get the FREE Sportsmen's Voice e-publication in your inbox every Monday: www.congressionalsportsmen.org/newsletter   Sign up for FREE legislative tracking through CSF's Tracking the Capitols tool: www.congressionalsportsmen.org/tracking-the-capitols/ Learn more about your ad choices. Visit megaphone.fm/adchoices

 Normal pressure hydrocephalus (NPH) is a clinical syndrome of gait abnormality, cognitive impairment, and urinary incontinence. Evaluation of CSF dynamics, patterns of fludeoxyglucose (FDG) uptake, and patterns of brain stiffness may aid in the evaluation of challenging cases that lack typical clinical and structural radiographic features. In this episode, Katie Grouse, MD, FAAN, speaks with Aaron Switzer, MD, MSc, author of the article “Radiographic Evaluation of Normal Pressure Hydrocephalus” in the Continuum® June 2025 Disorders of CSF Dynamics issue. Dr. Grouse is a Continuum® Audio interviewer and a clinical assistant professor at the University of California San Francisco in San Francisco, California. Dr. Switzer is a clinical assistant professor of neurology in the department of clinical neurosciences at the University of Calgary in Calgary, Alberta, Canada. Additional Resources Read the article: Radiographic Evaluation of Normal Pressure Hydrocephalus Subscribe to Continuum®: shop.lww.com/Continuum Earn CME (available only to AAN members): continpub.com/AudioCME Continuum® Aloud (verbatim audio-book style recordings of articles available only to Continuum® subscribers): continpub.com/Aloud More about the American Academy of Neurology: aan.com Social Media facebook.com/continuumcme @ContinuumAAN Full episode transcript available here Dr Jones: This is Dr Lyell Jones, Editor-in-Chief of Continuum. Thank you for listening to Continuum Audio. Be sure to visit the links in the episode notes for information about earning CME, subscribing to the journal, and exclusive access to interviews not featured on the podcast. Dr Grouse: This is Dr Katie Grouse. Today I'm interviewing Dr Aaron Switzer about his article on radiographic evaluation of normal pressure hydrocephalus, which he wrote with Dr Patrice Cogswell. This article appears in the June 2025 Continuum issue on disorders of CSF dynamics. Welcome to the podcast, and please introduce yourself to our audience. Dr. Switzer: Thanks so much for having me, Katie. I'm a neurologist that's working up in Calgary, Alberta, Canada, and I have a special interest in normal pressure hydrocephalus. So, I'm very happy to be here today to talk about the radiographic evaluation of NPH. Dr Grouse: I'm so excited to have you here today. It was really wonderful to read your article. I learned a lot on a topic that is not something that I frequently evaluate in my clinic. So, it's really just a pleasure to have you here to talk about this topic. So, I'd love to start by asking, what is the key message that you hope for neurologists who read your article to take away from it? Dr. Switzer: The diagnosis of NPH can be very difficult, just given the clinical heterogeneity in terms of how people present and what their images look like. And so, I'd like readers to know that detailed review of the patient's imaging can be very helpful to identify those that will clinically improve with shunt surgery. Dr Grouse: There's another really great article in this edition of Continuum that does a really great job delving into the clinical history and exam findings of NPH. So, I don't want to get into that topic necessarily today. However, I'd love to hear how you approach a case of a hypothetical patient, say, where you're suspicious of NPH based on the history and exam. I'd love to talk over how you approach the imaging findings when you obtain an MRI of the brain, as well as any follow-up imaging or testing that you generally recommend. Dr. Switzer: So, I break my approach down into three parts. First, I want to try to identify ventriculomegaly and any signs that would support that, and specifically those that are found in NPH. Secondly, I want to look for any alternative pathology or evidence of alternative pathology to explain the patient's symptoms. And then also evaluate any contraindications for shunt surgery. For the first one, usually I start with measuring Evans index to make sure that it's elevated, but then I want to measure one of the other four measurements that are described in the article, such as posterior colossal angle zed-Evans index---or z-Evans index for the American listeners---to see if there's any other features that can support normal pressure hydrocephalus. It's very important to identify whether there are features of disproportionately enlarged subarachnoid space hydrocephalus, or DESH, which can help identify patients who may respond to shunt surgery. And then if it's really a cloudy clinical picture, it's complicated, it's difficult to know, I would usually go through the full evaluation of the iNPH radscale to calculate a score in order to determine the likelihood that this patient has NPH. So, the second part of my evaluation is to rule out evidence of any alternative pathology to suggest another cause for the patient's symptoms, such as neurodegeneration or cerebrovascular disease. And then the third part of my evaluation is to look for any potential contraindications for shunt surgery, the main one being cerebral microbleed count, as a very high count has been associated with the hemorrhagic complications following shunt surgery. Dr Grouse: You mentioned about your use of the various scales to calculate for NPH, and your article does a great job laying them out and where they can be helpful. Are there any of these scales that can be reasonably relied on to predict the presence of NPH and responsiveness to shunt placement? Dr. Switzer: I think the first thing to acknowledge is that predicting shunt response is still a big problem that is not fully solved in NPH. So, there is not one single imaging feature, or even combination of imaging features, that can reliably predict shunt response. But in my view and in my practice, it's identifying DESH, I think, is really important---so, the disproportionately enlarged subarachnoid space hydrocephalus---as well as measuring the posterior colossal angle. I find those two features to be the most specific. Dr Grouse: Now you mentioned the concept of the NPH subtypes, and while this may be something that many of our listeners are familiar with, I suspect that, like myself when I was reading this article, there are many who maybe have not been keeping up to date on these various subtypes. Could you briefly tell us more about these NPH subtypes? Dr. Switzer: Sure. The Japanese guidelines for NPH have subdivided NPH into three different main categories. So that would be idiopathic, delayed onset congenital, and secondary normal pressure hydrocephalus. And so, I think the first to talk about would be the secondary NPH. We're probably all more familiar with that. That's any sort of pathology that could lead to disruption in CSF dynamics. These are things like, you know, a slow-growing tumor that is obstructing CSF flow or a widespread meningeal process that's reducing absorption of CSF, for instance. So, identifying these can be important because it may offer an alternative treatment for what you're seeing in the patient. The second important one is delayed onset congenital. And when you see an image of one of these subtypes, it's going to be pretty different than the NPH because the ventricles are going to be much larger, the sulcal enfacement is going to be more diffuse. Clinically, you may see that the patients have a higher head circumference. So, the second subtype to know about would be the delayed onset congenital normal pressure hydrocephalus. And when you see an image of one of these subtypes, it's going to be a little different than the imaging of NPH because the ventricles are going to be much larger, the sulcal enfacement is going to be more diffuse. And there are two specific subtypes that I'd like you to know about. The first would be long-standing overt ventriculomegaly of adulthood, or LOVA. And the second would be panventriculomegaly with a wide foramen of magendie and large discernomagna, which is quite a mouthful, so we just call it PAVUM. The importance of identifying these subtypes is that they may be amenable to different types of treatment. For instance, LOVA can be associated with aqueductal stenosis. So, these patients can get better when you treat them with an endoscopic third ventriculostomy, and then you don't need to move ahead with a shunt surgery. And then finally with idiopathic, that's mainly what we're talking about in this article with all of the imaging features. I think the important part about this is that you can have the features of DESH, or you can not have the features of DESH. The way to really define that would be how the patient would respond to a large-volume tap or a lumbar drain in order to define whether they have this idiopathic NPH. Dr Grouse: That's really helpful. And for those of our listeners who are so inclined, there is a wonderful diagram that lays out all these subtypes that you can take a look at. I encourage you to familiarize yourself with these different subtypes. Now it was really interesting to read in your article about some of the older techniques that we used quite some time ago for diagnosing normal pressure hydrocephalus that thankfully we're no longer using, including isotope encephalography and radionuclide cisternography. It certainly made me grateful for how we've come in our diagnostic tools for NPH. What do you think the biggest breakthrough in diagnostic tools that are now clinically available are? Dr. Switzer: You know, definitely the advent of structural imaging was very important for the evaluation of NPH, and specifically the identification of disproportionately enlarged subarachnoid space hydrocephalus, or DESH, in the late nineties has been very helpful for increasing the specificity of diagnosis in NPH. But some of the newer technologies that have become available would be phase-contrast MRI to measure the CSF flow rate through the aqueduct has been very helpful, as well as high spatial resolution T2 imaging to actually image the ventricular system and look for any evidence of expansion of the ventricles or obstruction of CSF flow. Dr Grouse: Regarding the scales that you had referenced earlier, do you think that we can look forward to more of these scales being automatically calculated and reported by various software techniques and radiographic interpretation techniques that are available or going to be available? Dr. Switzer: Definitely yes. And some of these techniques are already in development and used in research settings, and most of them are directed towards automatically detecting the features of DESH. So, that's the high convexity tight sulci, the focally enlarged sulci, and the enlarged Sylvian fissures. And separating the CSF from the brain tissue can help you determine where CSF flow is abnormal throughout the brain and give you a more accurate picture of CSF dynamics. And this, of course, is all automated. So, I do think that's something to keep an eye out for in the future. Dr Grouse: I wanted to ask a little more about the CSF flow dynamics, which I think may be new to a lot of our listeners, or certainly something that we've only more recently become familiar with. Can you tell us more about these advances and how we can apply this information to our evaluations for NPH? Dr. Switzer: So currently, only the two-dimensional phase contrast MRI technique is available on a clinical basis in most centers. This will measure the actual flow rate through the cerebral aqueduct. And so, in NPH, this can be elevated. So that can be a good supporting marker for NPH. In the future, we can look forward to other techniques that will actually look at three-dimensional or volume changes over time and this could give us a more accurate picture of aberrations and CSF dynamics. Dr Grouse: Well, definitely something to look forward to. And on the topic of other sort of more cutting-edge or, I think, less commonly-used technologies, you also mentioned some other imaging modalities, including diffusion imaging, intrathecal gadolinium imaging, nuclear medicine studies, MR elastography, for example. Are any of these modalities particularly promising for NPH evaluations, in your opinion? Do you think any of these will become more popularly used? Dr. Switzer: Yes, I think that diffusion tract imaging and MR elastography are probably the ones to keep your eye out for. They're a little more widely applicable because you just need an MR scanner to acquire the images. It's not invasive like the other techniques mentioned. So, I think it's going to be a lot easier to implement into clinical practice on a wide scale. So, those would be the ones that I would look out for in the future. Dr Grouse: Well, that's really exciting to hear about some of these techniques that are coming that may help us even more with our evaluation. Now on that note, I want to talk a little bit more about how we approach the evaluation and, in your opinion, some of the biggest pitfalls in the evaluation of NPH that you've found in your career. Dr. Switzer: I think there are three of note that I'd like to mention. The first would be overinterpreting the Evans index. So, just because an image shows that there's an elevated Evans index does not necessarily mean that NPH is present. So that's where looking for other corroborating evidence and looking for the clinical features is really important in the evaluation. Second would be misidentifying the focally enlarged sulci as atrophy because when you're looking at a brain with these blebs of CSF space in different parts of the brain, you may want to associate that to neurodegeneration, but that's not necessarily the case. And there are ways to distinguish between the two, and I think that's another common pitfall. And then third would be in regards to the CSF flow rate through the aqueduct. And so, an elevated CSF flow is suggestive of NPH, but the absence of that does not necessarily rule NPH out. So that's another one to be mindful of. Dr Grouse: That's really helpful. And then on the flip side, any tips or tricks or clinical pearls you can share with us that you found to be really helpful for the evaluation of NPH? Dr. Switzer: One thing that I found really helpful is to look for previous imaging, to look if there were features of NPH at that time, and if so, have they evolved over time; because we know that in idiopathic normal pressure hydrocephalus, especially in the dash phenotype, the ventricles can become larger and the effacement of the sulci at the convexity can become more striking over time. And this could be a helpful tool to identify how long that's been there and if it fits with the clinical history. So that's something that I find very helpful. Dr Grouse: Absolutely. When I read that point in your article, I thought that was really helpful and, in fact, I'm guessing something that a lot of us probably aren't doing. And yet many of our patients for one reason or other, probably have had imaging five, ten years prior to their time of evaluation that could be really helpful to look back at to see that evolution. Dr. Switzer: Yes, absolutely. Dr Grouse: It's been such a pleasure to read your article and talk with you about this today. Certainly a very important and helpful topic for, I'm sure, many of our listeners. Dr. Switzer: Thank you so much for having me. Dr Grouse: Again, today I've been interviewing Dr Aaron Switzer about his article on radiographic evaluation of normal pressure hydrocephalus, which he wrote with Dr Patrice Cogswell. This article appears in the most recent issue of Continuum on disorders of CSF dynamics. Be sure to check out Continuum Audio episodes from this and other issues, and thank you to our listeners for joining today. Dr Monteith: This is Dr Teshamae Monteith, Associate Editor of Continuum Audio. If you've enjoyed this episode, you'll love the journal, which is full of in-depth and clinically relevant information important for neurology practitioners. Use the link in the episode notes to learn more and subscribe. AAN members, you can get CME for listening to this interview by completing the evaluation at continpub.com/audioCME. Thank you for listening to Continuum Audio.

Quarter 2 Hunting, Fishing, and Conservation Policy Update – Federal Legislation, Fisheries Management & Public Lands   Narrative: In this Q2 federal policy roundup for hunters, anglers, and conservation advocates, we dive deep into the latest developments shaping the future of hunting, fishing, public lands, and forest management.   Hunting and Public Lands Policy with Taylor Schmitz First up, Director of Federal Relations Taylor Schmitz breaks down key federal policy shifts impacting sportsmen and women. From new Department of the Interior appointments to controversial proposals around public land sales, Taylor explains what these developments mean for hunting access, land conservation, and the broader outdoor community. Learn why Kate McGregor's return and Brian Nesvik's nomination matter to hunters and anglers, and why the upcoming congressional schedule is critical to follow.   Fishing and Fisheries Management with Chris Horton Next, Senior Director of Fisheries Policy Chris Horton joins to discuss top federal priorities affecting fishing and recreational anglers. He covers major legislation like the reauthorization of the Sport Fish Restoration and Boating Trust Fund and the Marine Fisheries Habitat Protection Act, along with the impact of shifting ocean conditions and the growing need for smarter fisheries management. Chris emphasizes collaboration between federal and state agencies and encourages all anglers to stay informed and active in fishing policy debates.   Forest Management and Timber Policy with John Culclasure To close out the episode, Senior Director of Forestry Policy John Culclasure provides an update on the Fix Our Forests Act and its implications for wildlife habitat, forest access, and timber production. He highlights how responsible forest management supports both conservation and hunting opportunities, while also touching on national security concerns tied to domestic timber supply. In addition, he discusses how state-level policies are affecting access to public lands for the hunting and fishing community.   Key Takeaways for Hunters and Anglers: Federal hunting and fishing policy is being shaped by new leadership at the Department of the Interior. Congress is tackling big-ticket items like public land sales that could impact millions of acres used for hunting and fishing. Reauthorization of the Sport Fish Restoration Fund is a major win for recreational fishing and boating access. Fisheries legislation aims to protect marine habitats and support sustainable sportfishing. Forest policy reform through the Fix Our Forests Act is crucial for maintaining habitat, access, and wildlife conservation. Misinformation around forest management could threaten future access for sportsmen. Domestic timber markets face challenges that could impact long-term forest health and hunting grounds. Active engagement by the hunting and fishing community is essential to protect our outdoor heritage and public lands.   Get the FREE Sportsmen's Voice e-publication in your inbox every Monday: www.congressionalsportsmen.org/newsletter                Sign up for FREE legislative tracking through CSF's Tracking the Capitols tool: www.congressionalsportsmen.org/tracking-the-capitols/ Learn more about your ad choices. Visit megaphone.fm/adchoices